CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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 1028 1578.250000 58275.0000 36.9238
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 29 39.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 325 884.250000 32717.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1138 2501.750000 90992.2500 36.3714
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 17.000000 1275.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 32.500000 2437.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.500000 487.5000 75.0000
Subtotal (Total Children Is Unduplicated) 38 93.000000 6514.3300 70.0466
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 2.750000 137.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 26 19.500000 975.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 0.750000 18.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 1.500000 75.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 148 116.000000 5800.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 14.750000 737.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 187 137.000000 6850.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 7 4.500000 112.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 6.250000 312.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 121 59.750000 2987.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 16 12.750000 637.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 149 97.750000 4887.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 99 201.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 0.250000 6.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 20 71.250000 3562.5000 50.0000
INTR-T1013-INTERPRETER 1 4.000000 300.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 142 354.000000 3490.0000 9.8588
OCCT-97530-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 8 22.750000 1625.2600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 285.7600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 25.000000 1786.0000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 78 66.250000 2451.2500 37.0000
TRAV-TRAVS-Travel by mile 30 1497.000000 666.0800 0.4449
Subtotal (Total Children Is Unduplicated) 431 2725.750000 38115.1100 13.9833
-----------------------------------------------------------------------------------------------------------------------
Total 5320.500000 135621.6900 25.4904
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1224
-----------------------------------------------------------------------------------------------------------------------
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 1 0.500000 18.5000 0.0000
D 6 5.250000 194.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 49 87.000000 2446.9100 2446.9100
6166 5227.750000 132962.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6222 5320.500000 135621.6900 2446.9100