CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 225.0000 90.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
Subtotal (Total Children Is Unduplicated) 12 23.000000 1655.2500 71.9674
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Total 23.000000 1655.2500 71.9674
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Number of Children (Unduplicated) With at Least One Service 12
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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 1 1.500000 83.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.500000 337.5000 0.0000
T 0 0.000000 0.0000 0.0000
10 17.000000 1234.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14 23.000000 1655.2500 0.0000