CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
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
EVAL-96111-DEVELOPMENTAL EVALUATION 1 0.750000 37.5000 50.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 8.500000 637.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 26.500000 1987.5000 75.0000
Subtotal (Total Children Is Unduplicated) 27 40.250000 2931.7500 72.8385
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Total 40.250000 2931.7500 72.8385
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Number of Children (Unduplicated) With at Least One Service 27
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Center 04
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
33 40.250000 2931.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 33 40.250000 2931.7500 0.0000