CMS/EIP Fiscal Report Center: 51
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:TPIN
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 1.000000 80.9800 80.9800
Subtotal (Total Children Is Unduplicated) 1 1.000000 80.9800 80.9800
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 162.0000 54.0000
Subtotal (Total Children Is Unduplicated) 2 4.000000 212.0000 53.0000
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Total 5.000000 292.9800 58.5960
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Number of Children (Unduplicated) With at Least One Service 3
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Center 51
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 3 3.000000 162.0000 162.0000
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
2 2.000000 130.9800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5 5.000000 292.9800 162.0000