CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:LEA
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 6 12.000000 422.0000 35.1667
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 19 33.500000 1088.5000 32.4925
Subtotal (Total Children Is Unduplicated) 25 45.500000 1510.5000 33.1978
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 9 83.500000 4175.0000 50.0000
Subtotal (Total Children Is Unduplicated) 9 83.500000 4175.0000 50.0000
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Total 129.000000 5685.5000 44.0736
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Number of Children (Unduplicated) With at Least One Service 34
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Center 52
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
50 129.000000 5685.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 50 129.000000 5685.5000 0.0000