CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 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
EVAL-96111-DEVELOPMENTAL EVALUATION 6 11.308600 565.4300 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.333333 475.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 115 200.759599 15056.9700 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 13.333334 1000.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 31.905066 2392.8800 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 48.257999 3619.3500 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 137 333.897931 24759.6300 74.1533
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Total 333.897931 24759.6300 74.1533
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Number of Children (Unduplicated) With at Least One Service 137
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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 50 100.000000 7500.0000 7500.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 42 84.000000 6250.0000 0.0000
T 0 0.000000 0.0000 0.0000
95 149.897931 11009.6300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 187 333.897931 24759.6300 7500.0000