CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:GR
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 3 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 8.500000 457.8800 53.8682
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.000000 225.0000 75.0000
Subtotal (Total Children Is Unduplicated) 11 17.500000 1132.8800 64.7360
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12 27.000000 270.0000 10.0000
Subtotal (Total Children Is Unduplicated) 12 27.000000 270.0000 10.0000
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Total 44.500000 1402.8800 31.5254
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Number of Children (Unduplicated) With at Least One Service 17
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Center 51
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 25 35.500000 825.3800 825.3800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8 9.000000 577.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 33 44.500000 1402.8800 825.3800