CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.00 111.00 55.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.83 150.00 81.97
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.07 115.10 55.60
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.07 115.11 55.61
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 1.92 144.36 75.19
Subtotal (Total Children Is Unduplicated) 3 11.89 746.57 62.79
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Total 11.89 746.57 62.79
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Number of Children (Unduplicated) With at Least One Service 3
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Center 53
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 6 7.39 467.57 518.56
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
3 4.50 279.00 0.00
Other 0 0.00 0.00 0.00
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Total 9 11.89 746.57 518.56