CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2019 ending 06/30/2019 Date of Report:07/21/2019 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 960 1535.000000 56776.5000 36.9879
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 628 680.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 287 695.500000 25724.2500 36.9867
Subtotal (Total Children Is Unduplicated) 1118 2911.000000 82500.7500 28.3410
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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) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
EXIT-EXIT-EXIT ASSESSMENT 8 7.500000 375.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 18.000000 999.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 14.500000 1087.5000 75.0000
SCREEN-T1023-SCREENING 4 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 32 64.500000 3999.7800 62.0121
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 39 33.000000 1613.2500 48.8864
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 1.250000 31.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 269 481.500000 24050.0000 49.9481
CONIP-CONIP-CONSULT, ITDS PHONE 23 8.250000 206.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 122 91.500000 4550.0000 49.7268
CONOP-CONOP-CONSULT, OT, PHONE 4 1.250000 31.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 136 85.500000 4275.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 145 99.000000 4950.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 11 6.000000 150.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 575 1865.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 13.750000 343.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 278.250000 13912.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 851 6391.000000 63900.0000 9.9984
OCCT-97530-OT SESSION BY LICENSED OT 6 33.000000 2357.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 16.000000 1143.0400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 20.000000 1407.3600 70.3680
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 530 45693.00000 20326.9600 0.4449
Subtotal (Total Children Is Unduplicated) 862 55118.50000 143262.0100 2.5992
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Total 58094.000000 229762.5400 3.9550
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Number of Children (Unduplicated) With at Least One Service 1279
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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 1 1.000000 37.0000 0.0000
P 1 1.000000 10.0000 9.2500
D 10 9.750000 427.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 3935 27459.500000 48612.6500 48612.6500
T 8 5.000000 76.2500 76.2500
14315 30617.750000 180599.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18270 58094.000000 229762.5400 48698.1500