CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 8 17.500000 875.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 10 23.500000 1286.0000 54.7234
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 51.000000 2550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 1 5.500000 392.9200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 15.000000 1071.6000 71.4400
Subtotal (Total Children Is Unduplicated) 9 73.500000 4114.5200 55.9799
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Total 97.000000 5400.5200 55.6755
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Number of Children (Unduplicated) With at Least One Service 19
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Center 06
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
90 97.000000 5400.5200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 90 97.000000 5400.5200 0.0000