CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 4.00 200.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 24.50 1837.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.00 600.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.50 262.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 9.50 2250.00 236.84
Subtotal (Total Children Is Unduplicated) 24 49.50 5150.00 104.04
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Total 49.50 5150.00 104.04
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Number of Children (Unduplicated) With at Least One Service 24
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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 1 1.50 250.00 162.50
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 8 8.00 2000.00 0.00
T 0 0.00 0.00 0.00
27 40.00 2900.00 0.00
Other 0 0.00 0.00 0.00
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Total 36 49.50 5150.00 162.50