CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Payclass Filters:OTHER
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 2.000000 46.7300 23.3650
Subtotal (Total Children Is Unduplicated) 1 2.000000 46.7300 23.3650
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EI Services,Class #03
TRAV-TRAVS-Travel by mile 1 16.000000 7.1200 0.4450
Subtotal (Total Children Is Unduplicated) 1 16.000000 7.1200 0.4450
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Total 18.000000 53.8500 2.9917
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Number of Children (Unduplicated) With at Least One Service 2
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Center 52
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
2 18.000000 53.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2 18.000000 53.8500 0.0000