CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 06/30/2021 Date of Report:07/15/2021 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 2103 9797.500000 362230.2500 36.9717
Subtotal (Total Children Is Unduplicated) 2103 9797.500000 362230.2500 36.9717
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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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 23 43.000000 3225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 24 44.000000 3300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 19 37.500000 2812.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 9 19.000000 1425.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 14.000000 777.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 38 75.500000 4134.7500 54.7649
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 36.500000 2737.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 238 451.500000 33862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 52.500000 3937.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 229 428.500000 32137.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 170 311.000000 23325.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 489 1000.500000 55435.2500 55.4075
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 207 389.000000 29175.0000 75.0000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 688 2943.000000 198920.2900 67.5910
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 5.500000 137.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 91 263.500000 13175.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 730 7883.250000 394162.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 26.000000 1857.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 39 207.750000 14841.6600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 5 11.000000 785.8400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 89 668.250000 47739.7800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 8 12.000000 857.2800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 28 191.500000 13680.7600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 3 9.000000 642.9600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 55 538.500000 38470.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 21.000000 1500.2400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 46.000000 3250.5200 70.6635
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 9 25.000000 1786.0000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 101 893.500000 63752.6400 71.3516
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 970 10802.75000 596654.4400 55.2317
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Total 23543.250000 1157804.9800 49.1778
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Number of Children (Unduplicated) With at Least One Service 2139
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Center 53
Flag Claims Units Chgs Paid
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R 2403 2192.000000 104927.8400 0.0000
U 0 0.000000 0.0000 0.0000
B 3252 2892.250000 140184.9600 59.2500
P 13563 12114.750000 575358.1700 574142.4600
D 234 230.000000 13945.2800 0.0000
S 232 222.500000 13231.5200 0.0000
H 28 28.000000 1964.6000 0.0000
T 1 2.000000 74.0000 0.0000
5571 5830.750000 306451.6900 0.0000
Other 32 31.000000 1666.9200 229.2500
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Total 25316 23543.250000 1157804.9800 574430.9600