CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.392266 916.4000 123.9668
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 270.6600 135.3300
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.881441 916.4000 116.2738
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 270.6600 135.3300
Subtotal (Total Children Is Unduplicated) 6 25.273707 2785.1200 110.1983
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Total 25.273707 2785.1200 110.1983
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Number of Children (Unduplicated) With at Least One Service 6
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 2 3.273707 208.8400 208.8400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 22.000000 2576.2800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 13 25.273707 2785.1200 208.8400