CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Payclass Filters:TPIN
Eligibility Filter:DEI Only
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 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
Subtotal (Total Children Is Unduplicated) 1 4.00 261.00 65.25
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.50 84.32 168.64
Subtotal (Total Children Is Unduplicated) 1 0.50 84.32 168.64
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Total 4.50 345.32 76.74
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Number of Children (Unduplicated) With at Least One Service 1
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Center 10
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
3 4.50 345.32 0.00
Other 0 0.00 0.00 0.00
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Total 3 4.50 345.32 0.00