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
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 772 863.250000 31940.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 323 1512.750000 55934.7500 36.9755
Subtotal (Total Children Is Unduplicated) 918 2376.000000 87875.0000 36.9844
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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
Subtotal (Total Children Is Unduplicated) 289 518.000000 30549.5200 58.9759
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Total 2894.000000 118424.5200 40.9207
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Number of Children (Unduplicated) With at Least One Service 1028
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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 0 0.000000 0.0000 0.0000
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
2886 2894.000000 118424.5200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2886 2894.000000 118424.5200 0.0000