CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 24.000000 1800.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
Subtotal (Total Children Is Unduplicated) 12 30.000000 2250.0000 75.0000
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Total 30.000000 2250.0000 75.0000
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Number of Children (Unduplicated) With at Least One Service 12
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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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
15 30.000000 2250.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15 30.000000 2250.0000 0.0000