CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.500000 75.0000 50.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.3300 142.3300
Subtotal (Total Children Is Unduplicated) 2 2.500000 217.3300 86.9320
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.500000 12.5000 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 6.000000 2.6700 0.4450
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 0.750000 53.9700 71.9600
TRAV-TRAVS-Travel by mile 543 21748.00000 9687.8100 0.4455
Subtotal (Total Children Is Unduplicated) 545 21756.25000 9806.9500 0.4508
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Total 21758.750000 10024.2800 0.4607
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Number of Children (Unduplicated) With at Least One Service 547
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Center 06
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 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
2241 21758.750000 10024.2800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2241 21758.750000 10024.2800 0.0000