CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 10.00 750.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 9.00 499.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 1.50 112.50 75.00
Subtotal (Total Children Is Unduplicated) 12 26.50 1792.50 67.64
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 2 1.00 50.00 50.00
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Total 27.50 1842.50 67.00
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Number of Children (Unduplicated) With at Least One Service 12
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Center 01
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 12 12.50 742.50 0.00
S 0 0.00 0.00 0.00
H 1 1.00 75.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 14 14.00 1025.00 0.00
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Total 27 27.50 1842.50 0.00