CMS/EIP Fiscal Report Center: 55
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: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
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 4 10.000000 711.0000 71.1000
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 17.000000 1214.4800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 27.000000 1928.8800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 6 48.000000 3429.1200 71.4400
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Total 58.000000 4140.1200 71.3814
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Number of Children (Unduplicated) With at Least One Service 10
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Center 55
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 5 4.000000 285.7600 285.7600
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
66 54.000000 3854.3600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 71 58.000000 4140.1200 285.7600