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:MED
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 1027 2787.250000 103008.2500 36.9569
Subtotal (Total Children Is Unduplicated) 1027 2787.250000 103008.2500 36.9569
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 21.500000 1612.5000 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 8 16.000000 1200.0000 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 9 17.000000 943.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 109 197.000000 14775.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 74 132.500000 9937.5000 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 60 105.000000 7875.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 147 296.000000 16391.0000 55.3750
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 107.500000 8062.5000 75.0000
Subtotal (Total Children Is Unduplicated) 227 928.000000 63259.5400 68.1676
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 36 72.500000 3625.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 366 1718.000000 85900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 20.000000 1428.8000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 20 70.250000 5018.6600 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 8 12.000000 857.2800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 13 40.000000 2857.6000 71.4400
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 7 16.000000 1143.0400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 4.750000 339.3400 71.4400
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
Subtotal (Total Children Is Unduplicated) 523 2540.750000 142925.9800 56.2535
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Total 6256.000000 309193.7700 49.4236
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Number of Children (Unduplicated) With at Least One Service 1130
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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 1203 1120.750000 53041.5400 53041.5400
D 32 34.500000 2123.1800 0.0000
S 164 174.000000 11432.2600 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 74.0000 0.0000
1096 1152.250000 60974.6000 0.0000
Other 14 14.750000 811.1700 0.0000
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Total 6733 6256.000000 309193.7700 53041.5400