CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 09/30/2020 Date of Report:10/15/2020 Page: 1
List order: No List
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 946 1797.000000 66470.5000 36.9897
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 12 8.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1201 3362.250000 124294.0000 36.9675
Subtotal (Total Children Is Unduplicated) 1271 5168.000000 190764.5000 36.9126
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 17 31.000000 1720.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 51.500000 3862.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 55 102.500000 7687.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 16.500000 1237.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 61 111.500000 8362.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 36 63.500000 4762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 180 359.500000 19896.7500 55.3456
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 106 199.500000 14962.5000 75.0000
SCREEN-T1023-SCREENING 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 258 993.500000 66536.7900 66.9721
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EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 1.250000 62.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 14 11.750000 587.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 29 13.750000 687.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 259 278.750000 13937.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 3.250000 75.0000 23.0769
CONOF-CONOF-CONSULT, OT, FACE TO FACE 15 9.500000 475.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 214 145.500000 7275.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 27 15.250000 762.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 153 85.750000 4287.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 8.000000 400.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 232 210.000000 10487.5000 49.9405
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.500000 62.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 6.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 34 58.500000 2925.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 372 1747.500000 87375.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 47 175.750000 12555.5800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 50 223.500000 15966.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 27 152.500000 10894.6000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 33 157.250000 11233.9400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 41 193.500000 13787.9200 71.2554
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 41 232.250000 16591.9400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 69 79.250000 2932.2500 37.0000
TRAV-TRAVS-Travel by mile 1 42.000000 18.6900 0.4450
Subtotal (Total Children Is Unduplicated) 639 3859.250000 213783.2000 55.3950
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Total 10020.750000 471084.4900 47.0109
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Number of Children (Unduplicated) With at Least One Service 1333
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Center 53
Flag Claims Units Chgs Paid
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R 19 10.750000 423.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3469 3093.500000 147584.8000 0.0000
P 1373 1219.250000 58434.6500 58406.9000
D 51 43.000000 2060.3300 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 101 139.500000 4934.0200 4884.0200
8286 5422.000000 252005.3900 0.0000
Other 93 92.750000 5641.5500 9.2500
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Total 13392 10020.750000 471084.4900 63300.1700