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
Agency Filter:EIP DEI DEIP
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 772 863.250000 31940.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1408 7170.750000 265218.0000 36.9861
Subtotal (Total Children Is Unduplicated) 1448 8034.000000 297158.2500 36.9876
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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 17 18.500000 1387.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 18 20.500000 1537.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 19 31.500000 2362.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 39 75.500000 4190.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 80 86.000000 6450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 159 179.000000 13425.0000 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 267 530.500000 29442.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 131 176.000000 13170.7500 74.8338
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 75 76.000000 7663.3300 100.8333
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.000000 163.9400 23.4200
Subtotal (Total Children Is Unduplicated) 373 1257.000000 82643.5200 65.7466
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Total 9291.000000 379801.7700 40.8785
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Number of Children (Unduplicated) With at Least One Service 1448
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Center 04
Flag Claims Units Chgs Paid
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R 71 116.250000 4358.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2338 3819.000000 149552.2500 0.0000
P 1000 1657.250000 64481.2500 64452.5000
D 91 149.750000 5925.5000 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
3386 3548.750000 155484.5200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6886 9291.000000 379801.7700 64452.5000