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
Payclass Filters:GR
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 710 668.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 918 3497.250000 129398.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2184 8654.500000 295472.7500 34.1409
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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 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 55.000000 4125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 45.000000 3375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 91.500000 6862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 80.500000 4467.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 78.500000 5887.5000 75.0000
Subtotal (Total Children Is Unduplicated) 268 619.500000 38706.2500 62.4798
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 167 295.750000 14787.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 55 48.000000 1200.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 26 35.500000 1775.0000 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 24 28.000000 1400.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.250000 6.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 30 37.000000 1850.0000 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 436 2334.500000 116225.0000 49.7858
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 36 139.000000 9930.1600 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 222 1519.250000 107541.2000 70.7857
TRAV-TRAVS-Travel by mile 1455 110912.0000 48421.0000 0.4366
Subtotal (Total Children Is Unduplicated) 1662 116937.7500 349476.7900 2.9886
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Total 126211.750000 683655.7900 5.4167
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Number of Children (Unduplicated) With at Least One Service 2467
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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 16111 123066.000000 669325.2900 669325.2900
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
226 3144.750000 14255.5000 0.0000
Other 1 1.000000 75.0000 0.0000
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Total 16338 126211.750000 683655.7900 669325.2900