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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 9 10.000000 750.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.500000 249.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 61.000000 4545.7500 74.5205
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3952.0000 304.0000
Subtotal (Total Children Is Unduplicated) 60 91.000000 9655.7500 106.1071
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Total 91.000000 9655.7500 106.1071
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Number of Children (Unduplicated) With at Least One Service 60
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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
82 91.000000 9655.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 82 91.000000 9655.7500 0.0000