CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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 1041 1787.750000 66063.7500 36.9536
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 13.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1305 3478.500000 128639.7500 36.9814
Subtotal (Total Children Is Unduplicated) 1389 5280.000000 194703.5000 36.8757
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 39.4200 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 13.8700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 27.2400 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 166.9800 27.8300
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
EVAL-96111-DEVELOPMENTAL EVALUATION 4 7.000000 350.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 28 53.500000 2675.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 15.500000 1162.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 14 26.500000 1987.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 20 40.000000 2220.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 100 189.000000 14175.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 27.000000 2025.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 104 192.000000 14400.0000 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 71 128.500000 9637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 206 433.000000 24031.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 75 142.000000 10650.0000 75.0000
Subtotal (Total Children Is Unduplicated) 295 1313.500000 86980.2300 66.2202
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 3.750000 187.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 22 15.500000 775.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 15 6.250000 312.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 216 247.250000 12338.0000 49.9009
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 5.750000 287.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 168 127.000000 6350.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 5.000000 250.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 127 65.000000 3250.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 21 15.750000 762.5000 48.4127
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 127 108.750000 5437.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 12 26.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 24 41.500000 2075.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 488 2488.250000 124412.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10 16.000000 160.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 7.000000 500.0800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 54 224.250000 15998.9800 71.3444
OCCT-97530TL-OT SESSION BY LICENSED OT 3 8.000000 571.5200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 32 124.000000 8858.5600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 7.750000 553.6600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 27 153.250000 10948.1800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 22 126.750000 9055.0200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 6.000000 428.6400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 40 142.250000 10162.3400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 40 214.000000 15266.7200 71.3398
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 33 50.500000 1868.5000 37.0000
TRAV-TRAVS-Travel by mile 5 66.000000 29.3500 0.4447
Subtotal (Total Children Is Unduplicated) 708 4305.250000 230973.4900 53.6493
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Total 10898.750000 512657.2200 47.0382
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Number of Children (Unduplicated) With at Least One Service 1464
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Center 53
Flag Claims Units Chgs Paid
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R 56 58.750000 2311.5100 0.0000
U 0 0.000000 0.0000 0.0000
B 2776 2543.750000 123329.4900 0.0000
P 2196 1953.000000 92973.6000 92973.6000
D 297 237.500000 11626.8600 0.0000
S 87 65.000000 2880.7600 0.0000
H 0 0.000000 0.0000 0.0000
T 86 85.500000 4294.2500 4219.2500
8335 5915.500000 272841.2700 0.0000
Other 43 39.750000 2399.4800 101.7500
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Total 13876 10898.750000 512657.2200 97294.6000