CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.233733 17.5300 75.0001
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 28.200000 2115.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 6.200000 465.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 18.000000 1350.0000 75.0000
Subtotal (Total Children Is Unduplicated) 19 54.633733 4097.5300 75.0000
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Total 54.633733 4097.5300 75.0000
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Number of Children (Unduplicated) With at Least One Service 19
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Center 55
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 7 14.000000 1050.0000 1050.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 11 22.000000 1650.0000 0.0000
T 0 0.000000 0.0000 0.0000
12 18.633733 1397.5300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 30 54.633733 4097.5300 1050.0000