CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 21.000000 1165.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 13.000000 975.0000 75.0000
Subtotal (Total Children Is Unduplicated) 14 44.000000 2890.5000 65.6932
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 4.000000 200.0000 50.0000
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Total 48.000000 3090.5000 64.3854
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Number of Children (Unduplicated) With at Least One Service 15
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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 0 0.000000 0.0000 0.0000
8 12.000000 752.5000 0.0000
Other 23 36.000000 2338.0000 0.0000
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Total 31 48.000000 3090.5000 0.0000