CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 9 21.000000 1455.2500 69.2976
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 100.0000 50.0000
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Total 23.000000 1555.2500 67.6196
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Number of Children (Unduplicated) With at Least One Service 10
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Center 05
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 100.0000 100.0000
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
15 21.000000 1455.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16 23.000000 1555.2500 100.0000