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
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 951 1469.250000 54325.2500 36.9748
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 622 663.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 298 715.000000 26418.0000 36.9483
Subtotal (Total Children Is Unduplicated) 1110 2847.250000 80743.2500 28.3583
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Screening, Eval, and Assessment,Class #02
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-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 9 10.750000 537.5000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 17.000000 943.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 24.500000 1837.5000 75.0000
SCREEN-T1023-SCREENING 4 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 37 78.750000 4878.6500 61.9511
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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 1960.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 35 157.000000 7850.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 793 5444.000000 54440.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 8.000000 571.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 20.000000 1428.8000 71.4400
TRAV-TRAVS-Travel by mile 419 28738.00000 12784.5800 0.4449
Subtotal (Total Children Is Unduplicated) 796 37098.75000 115266.8800 3.1070
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Total 40024.750000 200888.7800 5.0191
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Number of Children (Unduplicated) With at Least One Service 1249
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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 3 3.000000 77.7500 96.2500
D 7 6.500000 240.5000 0.0000
S 2 2.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2693 17537.500000 31553.1700 31553.1700
13490 22475.750000 169017.3600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16195 40024.750000 200888.7800 31649.4200