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: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 2514 6827.750000 252387.7500 36.9650
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 63 77.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 957 3585.000000 132451.5000 36.9460
Subtotal (Total Children Is Unduplicated) 2728 10490.00000 384839.2500 36.6863
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 59.1300 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 55.4800 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 36.3200 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 194.8100 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 44.8000 22.4000
EVAL-96111-DEVELOPMENTAL EVALUATION 8 14.000000 700.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 55 101.500000 5075.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 23 40.500000 3037.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 33 55.000000 4125.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 17 28.000000 2100.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 79 150.999900 8380.4945 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 44.000000 3300.0000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 185 485.999900 29212.2245 60.1075
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 293.3800 293.3800
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 24 17.000000 850.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 82 68.500000 3425.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 60 29.000000 1450.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 629 990.750000 49477.0000 49.9389
CONIP-CONIP-CONSULT, ITDS PHONE 3 4.000000 93.7500 23.4375
CONOF-CONOF-CONSULT, OT, FACE TO FACE 45 30.250000 1512.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 533 575.000000 27525.0000 47.8696
CONOP-CONOP-CONSULT, OT, PHONE 12 9.750000 243.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 47 30.000000 1500.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 406 304.750000 15237.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 75 58.500000 2900.0000 49.5726
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 479 526.500000 26312.5000 49.9763
CONSP-CONSP-CONSULT, SLP, PHONE 11 8.000000 200.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 68 168.250000 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 4 12.000000 600.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 89 729.000000 36450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 81 204.000000 2040.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 19 81.250000 5804.5000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 8.000000 571.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 6.000000 428.6400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 8 19.750000 1410.9400 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 15 65.500000 4679.3200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 128 208.750000 7723.7500 37.0000
TRAV-TRAVS-Travel by mile 15 773.000000 343.9500 0.4450
Subtotal (Total Children Is Unduplicated) 882 4935.500000 191387.3200 38.7777
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Total 15911.499900 605438.7945 38.0504
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Number of Children (Unduplicated) With at Least One Service 2764
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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 3 0.750000 34.2500 0.0000
P 2 1.000000 37.0000 18.5000
D 149 103.750000 4494.3200 0.0000
S 24 12.250000 576.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 926 1195.250000 46003.2400 45831.4900
25101 14598.499900 554293.2345 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 26205 15911.499900 605438.7945 45849.9900