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:GR
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 1072 1661.500000 61438.7500 36.9779
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 34.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 374 961.250000 35529.2500 36.9615
Subtotal (Total Children Is Unduplicated) 1216 2656.750000 96968.0000 36.4987
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
EVAL-96111-DEVELOPMENTAL EVALUATION 4 7.000000 350.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 27 48.000000 2400.0000 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 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.500000 787.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 24.500000 1837.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 34.000000 1887.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 55 140.500000 8394.5800 59.7479
-----------------------------------------------------------------------------------------------------------------------
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 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 25 88.000000 4400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 77 181.000000 1810.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 4 5.750000 410.7800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 6.000000 428.6400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 3 9.000000 642.9600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 14.000000 1000.1600 71.4400
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) 388 1749.500000 43829.4500 25.0526
-----------------------------------------------------------------------------------------------------------------------
Total 4546.750000 149192.0300 32.8129
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1285
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
D 6 5.250000 231.2500 0.0000
S 2 2.750000 101.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 101 283.000000 4885.8700 4885.8700
6680 4255.750000 143973.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6789 4546.750000 149192.0300 4885.8700