CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2019 ending 06/30/2019 Date of Report:07/21/2019 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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 23.000000 1276.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 17.500000 1312.5000 75.0000
Subtotal (Total Children Is Unduplicated) 20 54.500000 3639.0000 66.7706
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Total 54.500000 3639.0000 66.7706
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Number of Children (Unduplicated) With at Least One Service 20
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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
20 30.000000 2055.0000 0.0000
Other 15 24.500000 1584.0000 0.0000
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Total 35 54.500000 3639.0000 0.0000