CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 836 1122.500000 41532.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 562 644.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 266 704.000000 26029.5000 36.9737
Subtotal (Total Children Is Unduplicated) 993 2470.500000 67562.0000 27.3475
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 13.8700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.1600 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 8 8.250000 412.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 13.500000 749.2500 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 17.500000 1312.5000 75.0000
Subtotal (Total Children Is Unduplicated) 41 86.750000 5419.8600 62.4768
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 49.4300 49.4300
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 27 20.750000 1037.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 276 541.750000 27087.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 23 7.500000 181.5000 24.2000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 166 104.000000 5187.5000 49.8798
CONOP-CONOP-CONSULT, OT, PHONE 18 7.250000 181.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 143 93.250000 4650.0000 49.8660
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 81 54.500000 2725.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 7 2.000000 50.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 18.000000 1319.7600 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 604 1854.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 56 188.000000 9400.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 140.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 882 6451.000000 64490.0000 9.9969
OCCT-97530-OT SESSION BY LICENSED OT 1 0.750000 53.5800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 9.000000 642.9600 71.4400
TRAV-TRAVS-Travel by mile 534 45427.00000 20220.5900 0.4451
Subtotal (Total Children Is Unduplicated) 883 54793.50000 137691.5700 2.5129
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Total 57350.750000 210673.4300 3.6734
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Number of Children (Unduplicated) With at Least One Service 1166
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 1 1.000000 73.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 2186 15591.250000 24784.2500 24784.2500
T 3396 28755.500000 38073.8100 38073.8100
11756 13003.000000 147742.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 17339 57350.750000 210673.4300 62858.0600