CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 8 16.000000 800.0000 50.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 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 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 23.500000 1762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 52.500000 3937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 23.000000 1276.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 28.500000 2137.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 9.000000 450.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 16 63.000000 3150.0000 50.0000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 95 233.500000 14836.8500 63.5411
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 145 252.750000 12625.0000 49.9505
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 2 3.500000 175.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 73 76.000000 1900.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 12 17.000000 825.0000 48.5294
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 6.000000 300.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 18.000000 900.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 23 32.000000 1600.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 2.000000 100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 423 2442.000000 122100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 58 76.000000 3800.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 91 619.000000 6190.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 64 349.000000 24932.5600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 10 15.000000 1071.6000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 74 426.250000 30451.3000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
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 207 1306.000000 93300.6400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 21 40.500000 2893.3200 71.4400
TRAV-TRAVS-Travel by mile 1465 117008.0000 51088.3900 0.4366
Subtotal (Total Children Is Unduplicated) 1558 122699.0000 355037.6900 2.8936
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Total 122932.500000 369874.5400 3.0088
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Number of Children (Unduplicated) With at Least One Service 1588
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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 5373 119461.500000 359187.8200 359187.8200
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
141 3467.000000 10386.7200 0.0000
Other 2 4.000000 300.0000 0.0000
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Total 5516 122932.500000 369874.5400 359187.8200