CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 150.0000 75.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 17 47.750000 2386.5000 49.9791
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 2.000000 100.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 20 50.750000 2558.4600 50.4130
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Total 52.750000 2708.4600 51.3452
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Number of Children (Unduplicated) With at Least One Service 21
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Center 01
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 51 50.750000 2558.4600 0.0000
S 1 2.000000 150.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 52 52.750000 2708.4600 0.0000