CMS/EIP Fiscal Report Center: 53
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: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 927 1405.750000 51930.5000 36.9415
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 17.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 310 789.500000 29100.5000 36.8594
Subtotal (Total Children Is Unduplicated) 1008 2212.500000 81031.0000 36.6242
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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-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 27.7400 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 22.4000 22.4000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.000000 975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 13 27.500000 1526.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 25 68.000000 4170.5100 61.3310
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.500000 225.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 24 20.250000 1012.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 12 5.000000 250.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 204 230.000000 11464.0000 49.8435
CONIP-CONIP-CONSULT, ITDS PHONE 2 0.750000 18.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 3.750000 187.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 133 129.000000 5250.0000 40.6977
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 6.000000 300.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 115 57.500000 2875.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 22 14.750000 737.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 106 79.250000 3962.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 5 7.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 45 195.250000 9762.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 2.000000 20.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 4 5.500000 392.9200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 19.000000 1357.3600 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 35 43.750000 1618.7500 37.0000
Subtotal (Total Children Is Unduplicated) 318 828.500000 39637.8600 47.8429
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Total 3109.000000 124839.3700 40.1542
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Number of Children (Unduplicated) With at Least One Service 1059
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Center 53
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 13 8.750000 392.6300 0.0000
S 7 2.500000 125.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 143 130.000000 6254.7600 4606.7600
5240 2967.750000 118066.9800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5403 3109.000000 124839.3700 4606.7600