CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:LEA
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 7 11.50 383.25 33.33
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 14.50 887.50 61.21
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
Subtotal (Total Children Is Unduplicated) 17 28.00 1420.75 50.74
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.00 100.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 55 246.50 12325.00 50.00
Subtotal (Total Children Is Unduplicated) 55 248.75 12431.25 49.97
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Total 276.75 13852.00 50.05
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Number of Children (Unduplicated) With at Least One Service 72
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Center 52
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
109 276.75 13852.00 0.00
Other 0 0.00 0.00 0.00
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Total 109 276.75 13852.00 0.00