CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
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 8 9.206200 690.4700 75.0005
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.768000 282.6000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
Subtotal (Total Children Is Unduplicated) 8 15.974200 1198.0700 75.0003
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Total 15.974200 1198.0700 75.0003
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Number of Children (Unduplicated) With at Least One Service 8
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Center 55
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.500000 112.5000 0.0000
T 0 0.000000 0.0000 0.0000
12 14.474200 1085.5700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 13 15.974200 1198.0700 0.0000