CMS/EIP Fiscal Report Center: 05
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
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 75.0000 75.0000
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EI Services,Class #03
PHY-97110GT-PT SESSION BY LICENSED PT 1 5.000000 357.2000 71.4400
Subtotal (Total Children Is Unduplicated) 1 5.000000 357.2000 71.4400
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Total 6.000000 432.2000 72.0333
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Number of Children (Unduplicated) With at Least One Service 2
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Center 05
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 4 6.000000 432.2000 432.2000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4 6.000000 432.2000 432.2000