CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 6.000000 222.0000 37.0000
Subtotal (Total Children Is Unduplicated) 3 6.000000 222.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 2 4.000000 300.0000 75.0000
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 1 2.000000 142.8800 71.4400
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Total 12.000000 664.8800 55.4067
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Number of Children (Unduplicated) With at Least One Service 6
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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 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
16 12.000000 664.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16 12.000000 664.8800 0.0000