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
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 1984 5197.500000 192307.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 534 565.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 908 3492.250000 129167.0000 36.9868
Subtotal (Total Children Is Unduplicated) 2122 9255.250000 321474.5000 34.7343
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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 118 237.000000 11850.0000 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 3.500000 262.5000 75.0000
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 4 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 55 92.500000 6937.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 45.000000 3375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 58 98.000000 7350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 57 99.500000 5522.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 57.500000 4312.5000 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) 278 731.000000 44996.1000 61.5542
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 154 268.750000 13425.0000 49.9535
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 3 5.500000 275.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 77 84.250000 2106.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 14 20.000000 975.0000 48.7500
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 18 22.000000 1100.0000 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
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 198 252.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 446 2547.000000 127350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 61 79.000000 3950.0000 50.0000
INTR-T1013-INTERPRETER 110 220.500000 11025.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 91 619.000000 6190.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 68 363.000000 25932.7200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 12 17.000000 1214.4800 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 213 1341.000000 95801.0400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 26 45.500000 3250.5200 71.4400
TRAV-TRAVS-Travel by mile 1473 117243.0000 51191.7600 0.4366
Subtotal (Total Children Is Unduplicated) 1673 123604.0000 377022.9500 3.0502
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Total 133590.250000 743493.5500 5.5655
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Number of Children (Unduplicated) With at Least One Service 2416
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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 17306 130113.750000 732419.3300 732400.8300
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 6 9.500000 687.5000 0.0000
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Total 17453 133590.250000 743493.5500 732400.8300