CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 11.500000 862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 27.000000 1498.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 14.500000 1016.5700 70.1083
Subtotal (Total Children Is Unduplicated) 23 59.500000 3826.0700 64.3037
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.000000 400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 8.000000 400.0000 50.0000
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Total 67.500000 4226.0700 62.6084
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Number of Children (Unduplicated) With at Least One Service 24
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Center 01
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 25 33.000000 1862.8200 1862.8200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 16 18.500000 1260.7500 0.0000
T 0 0.000000 0.0000 0.0000
3 3.500000 243.0000 0.0000
Other 8 12.500000 859.5000 0.0000
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Total 52 67.500000 4226.0700 1862.8200