CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 150.0000 75.0000
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 7.000000 358.0000 51.1429
EPIC-99601-Early Steps Professional Development Fee 1 1.000000 15.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 4.000000 48.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 0.750000 53.9700 71.9600
TRAV-TRAVS-Travel by mile 11 195.000000 86.7300 0.4448
Subtotal (Total Children Is Unduplicated) 20 208.750000 633.6600 3.0355
-----------------------------------------------------------------------------------------------------------------------
Total 210.750000 783.6600 3.7184
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
29 210.750000 783.6600 199.6000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29 210.750000 783.6600 199.6000