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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 824 909.000000 33633.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 343 1600.750000 59190.7500 36.9769
Subtotal (Total Children Is Unduplicated) 982 2509.750000 92823.7500 36.9853
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 52 57.000000 2850.0000 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 2 2.000000 150.0000 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 32 47.000000 2608.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 26 29.000000 2175.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 29 32.500000 2437.5000 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 187 283.000000 15706.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 38.500000 2887.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 56 57.000000 3357.8700 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) 316 564.500000 33330.1000 59.0436
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 148 891.000000 44550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 46 301.750000 15087.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 815 5874.000000 58740.0000 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) 856 7122.500000 121793.9600 17.0999
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Total 10196.750000 247947.8100 24.3164
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Number of Children (Unduplicated) With at Least One Service 1516
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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 1903 7052.500000 120104.9300 120104.9300
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
3087 3073.250000 126102.8000 0.0000
Other 5 26.000000 860.0000 800.0000
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Total 5009 10196.750000 247947.8100 121775.0100