CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 09/30/2020 Date of Report:10/15/2020 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 896 1677.500000 62058.2500 36.9945
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 12 8.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1141 3071.000000 113517.7500 36.9644
Subtotal (Total Children Is Unduplicated) 1211 4757.250000 175576.0000 36.9070
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 24.500000 1359.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 42.500000 3187.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 46 86.500000 6487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 13.500000 1012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 54 100.500000 7537.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 24 44.500000 3337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 143 289.000000 15984.0000 55.3080
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 83 159.500000 11962.5000 75.0000
SCREEN-T1023-SCREENING 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 207 807.000000 54089.7900 67.0258
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EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 1.250000 62.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 14 11.750000 587.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 29 13.750000 687.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 259 278.750000 13937.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 3.250000 75.0000 23.0769
CONOF-CONOF-CONSULT, OT, FACE TO FACE 15 9.500000 475.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 214 145.500000 7275.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 27 15.250000 762.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 153 85.750000 4287.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 8.000000 400.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 232 210.000000 10487.5000 49.9405
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.500000 62.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 6.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 34 58.500000 2925.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 372 1747.500000 87375.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 47 175.750000 12555.5800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 50 223.500000 15966.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 26 151.750000 10841.0200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 33 157.250000 11233.9400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 41 193.500000 13787.9200 71.2554
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 41 232.250000 16591.9400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 69 79.250000 2932.2500 37.0000
TRAV-TRAVS-Travel by mile 1 42.000000 18.6900 0.4450
Subtotal (Total Children Is Unduplicated) 638 3858.500000 213729.6200 55.3919
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Total 9422.750000 443395.4100 47.0558
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Number of Children (Unduplicated) With at Least One Service 1273
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Center 53
Flag Claims Units Chgs Paid
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R 18 10.500000 414.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3267 2886.500000 137832.3000 0.0000
P 1277 1125.000000 54021.4000 53993.6500
D 51 43.000000 2060.3300 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 101 139.500000 4934.0200 4884.0200
7905 5125.500000 238491.3100 0.0000
Other 93 92.750000 5641.5500 9.2500
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Total 12712 9422.750000 443395.4100 58886.9200