CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
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 951 1469.250000 54325.2500 36.9748
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 622 663.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1084 2713.250000 100112.7500 36.8977
Subtotal (Total Children Is Unduplicated) 1227 4845.500000 154438.0000 31.8725
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 36.3200 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.000000 39.8400 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 83.4900 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 50.1000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 10 12.750000 637.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 25.000000 1387.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 56.500000 4237.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 44.500000 3337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 48.000000 3600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 147 261.500000 14485.5000 55.3939
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 128 229.000000 17137.5000 74.8362
SCREEN-T1023-SCREENING 5 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 246 715.750000 46720.2500 65.2745
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 5.000000 215.1600 43.0320
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 28 24.750000 1237.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 259 417.750000 20887.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 11 4.250000 106.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 140 103.750000 5187.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 9 4.250000 106.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 182 128.500000 6425.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 0.750000 18.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 108 73.000000 3637.5000 49.8288
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.750000 18.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 593 1961.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 23.500000 587.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 481 2447.500000 122375.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 793 5445.000000 54450.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 59 310.000000 22117.9200 71.3481
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 67 414.250000 29579.7400 71.4055
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 71 365.000000 26075.6000 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 419 28738.00000 12784.5800 0.4449
Subtotal (Total Children Is Unduplicated) 797 40471.25000 305919.0800 7.5589
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Total 46032.500000 507077.3300 11.0156
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Number of Children (Unduplicated) With at Least One Service 1315
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Center 53
Flag Claims Units Chgs Paid
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R 6 6.000000 325.3200 0.0000
U 0 0.000000 0.0000 0.0000
B 2318 2144.110000 102468.7300 186.5000
P 1670 1537.630000 70696.5100 71614.3900
D 63 63.250000 3731.3300 0.0000
S 3 2.250000 9.2500 0.0000
H 43 42.750000 3054.0600 0.0000
T 2719 17563.500000 32635.7800 32635.7800
15454 24515.260000 284933.4100 0.0000
Other 167 157.750000 9222.9400 0.0000
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Total 22443 46032.500000 507077.3300 104436.6700