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
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1927 4488.500000 166074.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 853 755.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2280 8202.250000 303437.0000 36.9944
Subtotal (Total Children Is Unduplicated) 2485 13446.00000 469511.5000 34.9183
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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 123 244.000000 12200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 28.000000 2055.0000 73.3929
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 25.000000 1875.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 30.000000 2054.0000 68.4667
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 31.500000 2362.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 43.500000 2414.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 306 467.000000 34590.0000 74.0685
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 177 304.000000 22685.0000 74.6217
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 221 367.500000 27332.9600 74.3754
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 443 746.500000 41068.3000 55.0145
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 208 326.500000 23725.5000 72.6662
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 9.000000 450.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 5 49.000000 2450.0000 50.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 189.2000 47.3000
Subtotal (Total Children Is Unduplicated) 838 2680.500000 175828.8100 65.5955
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 173 308.250000 15412.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 59 52.000000 1300.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 27 38.500000 1925.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 15 15.500000 775.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 25 29.000000 1450.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.250000 6.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 32 40.000000 2000.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 3.000000 75.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 252 333.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1317 9216.750000 460337.5000 49.9458
INTR-T1013-INTERPRETER 94 227.750000 11387.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 90 613.000000 6130.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 124 805.500000 55980.4300 69.4977
PHY-97110-PT SESSION BY LICENSED PT 220 1654.000000 117019.6100 70.7495
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 518 4384.750000 308563.0000 70.3719
TRAV-TRAVS-Travel by mile 1665 162485.0000 71005.5500 0.4370
Subtotal (Total Children Is Unduplicated) 1879 180213.0000 1053921.8400 5.8482
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Total 196339.500000 1699262.1500 8.6547
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Number of Children (Unduplicated) With at Least One Service 2670
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Center 09
Flag Claims Units Chgs Paid
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R 2 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 345 377.000000 15821.2500 0.0000
P 23603 183364.250000 1124433.1800 1128214.8600
D 4 4.000000 285.7600 0.0000
S 0 0.000000 0.0000 0.0000
H 413 569.750000 28409.7500 0.0000
T 6 10.000000 600.1900 693.1900
2963 11543.500000 495292.2700 0.0000
Other 281 469.500000 34364.2500 0.0000
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Total 27617 196339.500000 1699262.1500 1128908.0500