CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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-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 10 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.500000 449.1700 59.8893
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 16.000000 1165.0000 72.8125
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 29.000000 1509.5000 52.0517
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 18.000000 1163.1500 64.6194
Subtotal (Total Children Is Unduplicated) 33 87.500000 5522.8200 63.1179
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Total 87.500000 5522.8200 63.1179
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Number of Children (Unduplicated) With at Least One Service 33
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Center 09
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 33 51.000000 2903.5700 3102.2900
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
5 6.000000 331.7500 0.0000
Other 20 30.500000 2287.5000 0.0000
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Total 58 87.500000 5522.8200 3102.2900