CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 3 5.38 403.42 74.99
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.65 274.10 75.10
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 5 10.53 790.02 75.03
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Total 10.53 790.02 75.03
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Number of Children (Unduplicated) With at Least One Service 5
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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 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
7 10.53 790.02 0.00
Other 0 0.00 0.00 0.00
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Total 7 10.53 790.02 0.00