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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 2259 10782.00000 398574.5000 36.9667
Subtotal (Total Children Is Unduplicated) 2259 10782.00000 398574.5000 36.9667
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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 24 45.000000 3375.0000 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 23 44.500000 3337.5000 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 12 24.000000 1800.0000 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 44 86.500000 4745.2500 54.8584
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 38.500000 2887.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 297 554.000000 41550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 59.000000 4425.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 272 502.000000 37611.0000 74.9223
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 212 379.500000 28462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 603 1214.500100 67312.2555 55.4238
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 254 472.500000 35437.5000 75.0000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 840 3526.000100 238179.7955 67.5496
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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 40 208.750000 14913.1000 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) 971 10803.75000 596725.8800 55.2332
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Total 25111.750100 1233480.1755 49.1196
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Number of Children (Unduplicated) With at Least One Service 2295
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Center 53
Flag Claims Units Chgs Paid
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R 2556 2350.000000 112204.8400 0.0000
U 0 0.000000 0.0000 0.0000
B 3538 3175.250000 153343.9600 59.2500
P 14511 13103.500100 621766.4255 620550.7500
D 248 247.500000 14933.7800 0.0000
S 239 232.500000 13981.5200 0.0000
H 28 28.000000 1964.6000 0.0000
T 1 2.000000 74.0000 0.0000
5638 5941.750000 313534.8800 0.0000
Other 33 31.250000 1676.1700 238.5000
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Total 26792 25111.750100 1233480.1755 620848.5000