CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
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-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 5 10.000000 500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.000000 975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 23.000000 1725.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 40.500000 3037.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 24.500000 1359.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 44.000000 3300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 94 171.500000 12126.2500 70.7070
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 142 248.500000 12425.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 49 44.500000 1112.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 21 30.500000 1525.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 14 14.500000 725.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 19.000000 950.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 26 33.000000 1650.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 415 2227.500000 110875.0000 49.7755
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 90 613.000000 6130.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 35 133.000000 9501.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 71 390.500000 27468.6800 70.3423
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 220 1490.250000 105469.4400 70.7730
TRAV-TRAVS-Travel by mile 1447 110537.0000 48256.7800 0.4366
Subtotal (Total Children Is Unduplicated) 1517 115790.7500 326718.4200 2.8216
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Total 115962.250000 338844.6700 2.9220
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Number of Children (Unduplicated) With at Least One Service 1567
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Center 09
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 4834 112871.250000 326264.4200 326264.4200
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 0 0.000000 0.0000 0.0000
159 3090.000000 12505.2500 0.0000
Other 1 1.000000 75.0000 0.0000
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Total 4994 115962.250000 338844.6700 326264.4200