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:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 37 243.500000 9009.5000 37.0000
Subtotal (Total Children Is Unduplicated) 37 243.500000 9009.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 15.000000 1125.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 23 26.000000 1443.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 11.000000 825.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 58.9100 58.9100
Subtotal (Total Children Is Unduplicated) 25 60.000000 3976.9100 66.2818
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 4.000000 200.0000 50.0000
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Total 307.500000 13186.4100 42.8826
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Number of Children (Unduplicated) With at Least One Service 40
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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 28 50.500000 1981.5000 1981.5000
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
26 36.000000 1947.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 188 307.500000 13186.4100 1981.5000