CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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
EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 0.500000 35.7200 71.4400
Subtotal (Total Children Is Unduplicated) 1 0.500000 35.7200 71.4400
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Total 0.500000 35.7200 71.4400
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Number of Children (Unduplicated) With at Least One Service 1
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Center 10
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
1 0.500000 35.7200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1 0.500000 35.7200 0.0000