CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 Page: 1
List order: No List
Agency Filter:EXT
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 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 34 68.000000 5100.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 20 40.000000 3000.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 95 186.500000 13987.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 16 31.000000 1720.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.500000 1687.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 77.000000 3850.0000 50.0000
Subtotal (Total Children Is Unduplicated) 182 451.500000 31323.7500 69.3771
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1362.6000 1362.6000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 90 161.000000 8050.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 33 57.250000 2862.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 145 191.500000 4787.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 8 12.000000 600.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 9 13.000000 650.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 11 11.000000 550.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 3.000000 150.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 16 19.000000 950.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 7 7.000000 350.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 489 2954.500000 147725.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 578 3799.500000 189575.0000 49.8947
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 19 57.000000 570.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 107 597.750000 41900.4400 70.0969
OCCT-97530GT-OT SESSION BY LICENSED OT 62 343.000000 24253.8700 70.7110
PHY-97110-PT SESSION BY LICENSED PT 141 904.250000 60142.7000 66.5111
PHY-97110GT-PT SESSION BY LICENSED PT 72 383.000000 27361.5200 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 291 1742.500000 122711.4100 70.4226
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 192 1345.750000 93795.5400 69.6976
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
TRAV-TRAVS-Travel by mile 448 33601.00000 14708.0600 0.4377
Subtotal (Total Children Is Unduplicated) 1324 46226.00000 744355.3400 16.1025
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Total 46677.500000 775679.0900 16.6178
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Number of Children (Unduplicated) With at Least One Service 1431
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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 2029 20191.500000 291554.7100 291554.7100
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
2925 26237.500000 466120.6300 0.0000
Other 128 248.500000 18003.7500 0.0000
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Total 5082 46677.500000 775679.0900 291554.7100