CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Payclass Filters:MED
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 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 3.000000 194.2500 64.7500
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 5 6.000000 419.2500 69.8750
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 17.000000 850.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 17.000000 850.0000 50.0000
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Total 23.000000 1269.2500 55.1848
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Number of Children (Unduplicated) With at Least One Service 8
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Center 51
Flag Claims Units Chgs Paid
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R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 2.000000 138.7500 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
8 20.000000 1075.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11 23.000000 1269.2500 0.0000