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
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 1073 1662.000000 61457.2500 36.9779
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 34.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1386 3794.500000 140239.5000 36.9586
Subtotal (Total Children Is Unduplicated) 1502 5490.500000 201696.7500 36.7356
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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 2 2.000000 39.4200 19.7100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 111.3200 27.8300
EVAL-96111-DEVELOPMENTAL EVALUATION 4 7.000000 350.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 28 50.000000 2500.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 12 23.500000 1762.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 10 20.000000 1500.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 21.000000 1165.5000 55.5000
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 148 268.000000 20100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 15.000000 1125.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 120 216.000000 16200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 80 140.000000 10500.0000 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 206 414.000000 22967.7500 55.4777
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 125.500000 9412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 315 1337.000000 89803.5700 67.1680
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 7.250000 362.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 26 20.500000 1025.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 7 4.000000 200.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 210 224.500000 11225.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 11.500000 575.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 205 163.750000 8162.5000 49.8473
CONOP-CONOP-CONSULT, OT, PHONE 10 7.750000 193.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 3.750000 187.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 124 78.500000 3925.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 28 20.000000 1000.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 185 129.000000 6450.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 3.000000 75.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 59 126.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 97.750000 4887.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 448 2074.750000 103737.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 77 181.000000 1810.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 34.000000 2428.9600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 41 166.000000 11859.0400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 41 133.750000 9555.1000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 16 39.000000 2786.1600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 30 110.500000 7975.1000 72.1729
PHY-97110TL-PT SESSION BY LICENSED PT 3 9.000000 642.9600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 25 134.500000 9608.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 40.000000 2857.6000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 37 127.250000 9033.1800 70.9877
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 8 24.000000 1714.5600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 67 281.000000 20017.0800 71.2352
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 40 34.250000 1267.2500 37.0000
TRAV-TRAVS-Travel by mile 12 608.000000 270.5300 0.4450
Subtotal (Total Children Is Unduplicated) 720 4902.250000 224125.3300 45.7189
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Total 11729.750000 515625.6500 43.9588
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Number of Children (Unduplicated) With at Least One Service 1577
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Center 53
Flag Claims Units Chgs Paid
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R 2467 2237.000000 107346.8400 0.0000
U 0 0.000000 0.0000 0.0000
B 1756 1520.750000 73390.1800 0.0000
P 1205 1122.500000 53247.5400 53247.5400
D 41 42.250000 2533.0300 0.0000
S 166 176.750000 11534.0100 0.0000
H 0 0.000000 0.0000 0.0000
T 133 316.000000 6457.4100 6383.4100
8513 6265.750000 257962.2700 0.0000
Other 48 48.750000 3154.3700 0.0000
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Total 14329 11729.750000 515625.6500 59630.9500