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
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
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
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 22.000000 1650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 100.500000 5577.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 29.000000 2175.0000 75.0000
Subtotal (Total Children Is Unduplicated) 92 186.500000 11109.5000 59.5684
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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 3 2.250000 112.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 202 205.000000 10250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 64 38.000000 1900.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 40 29.500000 1475.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.250000 12.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 237 1132.500000 56625.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 476 2134.000000 21340.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 139.000000 9915.9200 71.3376
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 86.500000 6179.5600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 62.000000 4429.2800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 419 28701.00000 12768.1200 0.4449
Subtotal (Total Children Is Unduplicated) 478 32539.50000 125356.6200 3.8524
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Total 32726.000000 136466.1200 4.1700
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Number of Children (Unduplicated) With at Least One Service 480
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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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2719 17563.500000 32635.7800 32635.7800
3298 15162.500000 103830.3400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6017 32726.000000 136466.1200 32635.7800