CMS/EIP Fiscal Report Center: 55
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.86 1189.49 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.80 434.92 74.99
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 337.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.50 662.50 101.92
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 17 37.66 2894.91 76.87
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Total 37.66 2894.91 76.87
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Number of Children (Unduplicated) With at Least One Service 17
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Center 55
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 2 3.00 400.00 400.00
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
21 34.66 2494.91 0.00
Other 0 0.00 0.00 0.00
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Total 23 37.66 2894.91 400.00