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:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1095 5658.000000 209283.2500 36.9889
Subtotal (Total Children Is Unduplicated) 1095 5658.000000 209283.2500 36.9889
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 17 19.500000 1462.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 14.500000 1087.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 24 28.000000 1554.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 56 59.000000 4425.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 133 150.000000 11250.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 207 268.500000 14901.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 79.500000 5962.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 824.7400 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 70.2600 23.4200
Subtotal (Total Children Is Unduplicated) 253 648.000000 42438.2500 65.4911
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Total 6306.000000 251721.5000 39.9178
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Number of Children (Unduplicated) With at Least One Service 1096
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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
418 563.750000 27404.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3918 6306.000000 251721.5000 64452.5000