CMS/EIP Fiscal Report Center: 52
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 44.000000 3055.0000 69.4318
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 27.000000 1960.6500 72.6167
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 51.000000 2719.5000 53.3235
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 26 132.000000 8485.1500 64.2814
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Total 132.000000 8485.1500 64.2814
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Number of Children (Unduplicated) With at Least One Service 26
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Center 52
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 4 8.000000 600.0000 399.3500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 38.000000 2850.0000 0.0000
T 22 43.000000 2554.7300 2414.7300
22 43.000000 2480.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 67 132.000000 8485.1500 2814.0800