CMS/EIP Fiscal Report Center: 51
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 80.9800 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.500000 271.4700 77.5629
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 7.500000 595.3900 79.3853
Subtotal (Total Children Is Unduplicated) 10 12.000000 947.8400 78.9867
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 37.000000 1902.0000 51.4054
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 38.000000 1952.0000 51.3684
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Total 50.000000 2899.8400 57.9968
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Number of Children (Unduplicated) With at Least One Service 12
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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 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
49 50.000000 2899.8400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 49 50.000000 2899.8400 0.0000