CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 11.500000 862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 5 21.000000 1428.7500 68.0357
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 1 4.000000 285.7600 71.4400
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Total 25.000000 1714.5100 68.5804
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Number of Children (Unduplicated) With at Least One Service 6
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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 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 1 2.000000 150.0000 150.0000
14 23.000000 1564.5100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15 25.000000 1714.5100 150.0000