CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 15 24.571067 1842.8300 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 26.000000 1950.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 20 66.571067 4953.8300 74.4142
-----------------------------------------------------------------------------------------------------------------------
Total 66.571067 4953.8300 74.4142
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 20
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 11 21.377600 1564.3200 1564.3200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.666667 200.0000 0.0000
T 4 8.000000 600.0000 600.0000
20 34.526800 2589.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 37 66.571067 4953.8300 2164.3200