CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 Page: 1
List order: No List
Payclass Filters:TPIN
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 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 15 46.000000 1702.0000 37.0000
Subtotal (Total Children Is Unduplicated) 16 46.500000 1720.5000 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 83.4900 27.8300
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 27 50.500000 3787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 25 47.500000 3562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 23.000000 1725.0000 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 35 68.000000 3774.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
Subtotal (Total Children Is Unduplicated) 59 217.000000 14610.2000 67.3281
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 24.250000 1212.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 65 268.750000 13437.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 14.000000 1000.1600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 21 90.000000 6429.6000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 21.000000 1500.2400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 14 61.500000 4474.5400 72.7567
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 22.000000 1571.6800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 31 108.500000 7693.6800 70.9095
Subtotal (Total Children Is Unduplicated) 136 612.000000 37369.9000 61.0619
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Total 875.500000 53700.6000 61.3371
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Number of Children (Unduplicated) With at Least One Service 175
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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 2 1.750000 206.0000 206.0000
D 3 2.500000 178.6000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 31 31.000000 1497.5400 1497.5400
706 806.250000 49475.2600 0.0000
Other 34 34.000000 2343.2000 0.0000
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Total 776 875.500000 53700.6000 1703.5400