CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 31 26.000000 962.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 49 308.750000 11423.7500 37.0000
Subtotal (Total Children Is Unduplicated) 50 334.750000 12385.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.500000 75.0000 50.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 0.500000 37.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 9.000000 675.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 18.500000 1387.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 29 51.500000 2858.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 19.500000 1462.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 834.1900 83.4190
Subtotal (Total Children Is Unduplicated) 33 112.500000 7460.4400 66.3150
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 10.000000 500.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 10.000000 100.0000 10.0000
Subtotal (Total Children Is Unduplicated) 4 20.000000 600.0000 30.0000
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Total 467.250000 20446.1900 43.7586
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Number of Children (Unduplicated) With at Least One Service 50
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Center 04
Flag Claims Units Chgs Paid
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R 4 7.000000 259.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 121 199.500000 8409.7500 0.0000
P 33 66.500000 2381.5000 2381.5000
D 6 10.500000 388.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 4.000000 200.0000 0.0000
T 0 0.000000 0.0000 0.0000
169 179.750000 8807.4400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 336 467.250000 20446.1900 2381.5000