CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 3 7.000000 456.7500 65.2500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 17 35.272800 1763.6400 50.0000
Subtotal (Total Children Is Unduplicated) 17 35.272800 1763.6400 50.0000
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Total 42.272800 2220.3900 52.5253
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Number of Children (Unduplicated) With at Least One Service 18
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Center 54
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 14 9.272800 463.6400 705.6000
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
19 20.750000 1094.2500 0.0000
Other 12 12.250000 662.5000 0.0000
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Total 45 42.272800 2220.3900 705.6000