CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 2 6.000000 372.0000 62.0000
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EI Services,Class #03
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 11.000000 550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 21.000000 9.3500 0.4452
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
TRAV-TRAVS-Travel by mile 152 12634.00000 5627.1600 0.4454
Subtotal (Total Children Is Unduplicated) 156 12668.00000 6308.4700 0.4980
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Total 12674.000000 6680.4700 0.5271
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Number of Children (Unduplicated) With at Least One Service 158
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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
640 12674.000000 6680.4700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 640 12674.000000 6680.4700 0.0000