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
Payclass Filters:GR
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 12 65.250000 2414.2500 37.0000
Subtotal (Total Children Is Unduplicated) 35 91.250000 3376.2500 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-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 2 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 19 25.500000 1415.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.000000 225.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 471.2800 58.9100
Subtotal (Total Children Is Unduplicated) 26 45.500000 2729.5300 59.9897
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 6.000000 300.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 10.000000 100.0000 10.0000
Subtotal (Total Children Is Unduplicated) 4 16.000000 400.0000 25.0000
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Total 152.750000 6505.7800 42.5910
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Number of Children (Unduplicated) With at Least One Service 41
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Center 04
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 16.000000 400.0000 400.0000
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
136 136.750000 6105.7800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 141 152.750000 6505.7800 400.0000