CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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
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-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 27.500000 1526.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 16 47.500000 2987.2500 62.8895
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Total 47.500000 2987.2500 62.8895
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Number of Children (Unduplicated) With at Least One Service 16
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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 1 2.000000 150.0000 150.0000
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
23 45.500000 2837.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 24 47.500000 2987.2500 150.0000