CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.50 262.50 75.00
Subtotal (Total Children Is Unduplicated) 2 3.50 262.50 75.00
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 3.00 203.64 67.88
Subtotal (Total Children Is Unduplicated) 1 3.00 203.64 67.88
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Total 6.50 466.14 71.71
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Number of Children (Unduplicated) With at Least One Service 3
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Center 05
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
5 6.50 466.14 0.00
Other 0 0.00 0.00 0.00
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Total 5 6.50 466.14 0.00