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
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 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 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 30 59.500000 4462.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 77.000000 3850.0000 50.0000
Subtotal (Total Children Is Unduplicated) 62 173.000000 11031.0000 63.7630
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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 79 146.000000 7300.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 26 43.750000 2187.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 132 170.000000 4250.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 8 12.000000 600.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 6 9.000000 450.0000 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 15 18.000000 900.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 4 4.000000 200.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 176 971.500000 48575.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 211 1241.500000 61675.0000 49.6778
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 19 57.000000 570.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 65 370.500000 26468.5200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 39 185.000000 13216.4000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 74 522.250000 32978.4000 63.1468
PHY-97110GT-PT SESSION BY LICENSED PT 33 114.000000 8144.1600 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 147 756.500000 54044.3600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 105 640.500000 45757.3200 71.4400
TRAV-TRAVS-Travel by mile 434 28443.00000 12459.2800 0.4380
Subtotal (Total Children Is Unduplicated) 918 33736.50000 322780.5400 9.5677
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Total 33909.500000 333811.5400 9.8442
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Number of Children (Unduplicated) With at Least One Service 949
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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 1495 14763.750000 210133.1700 210133.1700
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
1039 19127.750000 122367.3700 0.0000
Other 9 18.000000 1311.0000 0.0000
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Total 2543 33909.500000 333811.5400 210133.1700