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
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 976 1482.500000 54751.7500 36.9320
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 17.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1185 3521.000000 130055.0000 36.9369
Subtotal (Total Children Is Unduplicated) 1290 5020.750000 184806.7500 36.8086
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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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 18.000000 943.5000 52.4167
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 98 188.000000 14100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 21.500000 1612.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 92 169.500000 12712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 55 101.500000 7612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 181 347.000000 19258.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 86 154.500000 11587.5000 75.0000
Subtotal (Total Children Is Unduplicated) 286 1046.500000 70667.7600 67.5277
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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
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 35 87.000000 4350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 433 2005.000000 100250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 2.000000 20.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 44 139.250000 9948.0200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 36 172.500000 12323.4000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 31 140.500000 10037.3200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 21 115.250000 8233.4600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 36 156.750000 11176.7800 71.3032
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 38 169.250000 12091.2200 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 35 43.750000 1618.7500 37.0000
Subtotal (Total Children Is Unduplicated) 668 3598.000000 196718.8400 54.6745
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Total 9665.250000 452193.3500 46.7855
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Number of Children (Unduplicated) With at Least One Service 1368
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Center 53
Flag Claims Units Chgs Paid
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R 11 11.750000 469.1900 0.0000
U 0 0.000000 0.0000 0.0000
B 3414 3075.750000 145865.0400 0.0000
P 1376 1337.250100 62490.3955 62180.6400
D 85 83.250000 4563.4200 0.0000
S 14 9.500000 475.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 163 152.000000 7382.2600 5406.7600
7175 4953.749900 228233.7845 0.0000
Other 46 42.000000 2714.2600 37.0000
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Total 12284 9665.250000 452193.3500 67624.4000