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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 793 883.000000 32671.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 331 1535.500000 56776.5000 36.9759
Subtotal (Total Children Is Unduplicated) 947 2418.500000 89447.5000 36.9847
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 51 55.500000 2775.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 5.500000 412.5000 75.0000
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 5 7.000000 525.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 31 46.000000 2553.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 24 27.000000 2025.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 26 29.000000 2175.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 168 257.500000 14291.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 35.500000 2662.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 48 49.000000 2886.5900 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 93.6800 23.4200
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 290 519.000000 30600.5700 58.9606
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 147 885.000000 44250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 46 301.750000 15087.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 811 5864.000000 58640.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 22.000000 1258.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 10.750000 614.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 12.000000 857.2800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 7.000000 400.1200 57.1600
Subtotal (Total Children Is Unduplicated) 852 7106.500000 121393.9600 17.0821
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Total 10044.000000 241442.0300 24.0384
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Number of Children (Unduplicated) With at Least One Service 1475
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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 1898 7036.500000 119704.9300 119704.9300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 14 45.000000 880.0800 870.0800
T 0 0.000000 0.0000 0.0000
2951 2936.500000 119997.0200 0.0000
Other 5 26.000000 860.0000 800.0000
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Total 4868 10044.000000 241442.0300 121375.0100