CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.000000 100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 3.500000 175.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.500000 107.1600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 2.500000 178.6000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 6.000000 428.6400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 13 17.500000 1070.8400 61.1909
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Total 17.500000 1070.8400 61.1909
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Number of Children (Unduplicated) With at Least One Service 13
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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
18 17.500000 1070.8400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18 17.500000 1070.8400 0.0000