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
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 17 36.750000 1359.7500 37.0000
Subtotal (Total Children Is Unduplicated) 17 36.750000 1359.7500 37.0000
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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-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 20 37.500000 2812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 25 45.500000 3412.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 18 34.500000 2587.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 35 63.000000 3496.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 18.000000 1350.0000 75.0000
Subtotal (Total Children Is Unduplicated) 68 246.500000 16305.4800 66.1480
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EI Services,Class #03
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 7.000000 350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 82 382.750000 19137.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 31 147.000000 10480.2400 71.2941
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 7.750000 553.6600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 17 118.750000 8483.5000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 31 115.750000 8269.1800 71.4400
Subtotal (Total Children Is Unduplicated) 159 786.000000 47731.2800 60.7268
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Total 1069.250000 65396.5100 61.1611
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Number of Children (Unduplicated) With at Least One Service 206
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Center 53
Flag Claims Units Chgs Paid
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R 31 36.750000 1359.7500 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 12 11.750000 839.4200 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 27 27.000000 1350.0000 1350.0000
866 963.500000 59836.3600 0.0000
Other 31 30.250000 2010.9800 0.0000
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Total 967 1069.250000 65396.5100 1350.0000