CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Payclass Filters:LEA
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
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 28.000000 2100.0000 75.0000
Subtotal (Total Children Is Unduplicated) 20 30.000000 2250.0000 75.0000
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Total 30.000000 2250.0000 75.0000
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Number of Children (Unduplicated) With at Least One Service 20
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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
20 30.000000 2250.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 20 30.000000 2250.0000 0.0000