CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 4 8.000000 635.8800 79.4850
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 38.000000 2885.8800 75.9442
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 611.9600 76.4950
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 27 56.000000 4283.7200 76.4950
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Total 56.000000 4283.7200 76.4950
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Number of Children (Unduplicated) With at Least One Service 27
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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 1 2.000000 150.0000 150.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 16 32.000000 2471.7600 0.0000
T 0 0.000000 0.0000 0.0000
11 22.000000 1661.9600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 28 56.000000 4283.7200 150.0000