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
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 1915 5527.500000 204499.0000 36.9967
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2011 7502.750000 277546.2500 36.9926
Subtotal (Total Children Is Unduplicated) 2208 13030.75000 482045.2500 36.9929
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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
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 12 22.000000 1650.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 9 17.000000 1275.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 14 24.500000 1359.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 208 353.000000 26297.5000 74.4972
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 131 227.500000 16963.9700 74.5669
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 175 335.000000 25075.0000 74.8507
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 353 616.500000 33725.0200 54.7040
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 29.500000 2212.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 77.000000 3850.0000 50.0000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 491 1755.000000 115827.8900 65.9988
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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 90 162.000000 8100.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 46 83.250000 4162.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 160 214.000000 5350.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 8 12.000000 600.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 10 14.000000 700.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 4.000000 100.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 11 11.000000 550.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 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 5 5.000000 250.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 20.000000 1000.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 9 10.000000 500.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 3.000000 75.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 13 10.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 510 2983.500000 149175.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 619 3940.500000 196625.0000 49.8985
INTR-T1013-INTERPRETER 57 146.750000 7337.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 19 57.000000 570.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 108 598.750000 41971.8800 70.0992
OCCT-97530GT-OT SESSION BY LICENSED OT 67 362.750000 25664.8100 70.7507
OCCT-97530TLGT-OT SESSION BY LICENSED OT 8 27.000000 1928.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 141 904.250000 60142.7000 66.5111
PHY-97110GT-PT SESSION BY LICENSED PT 73 384.000000 27432.9600 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 205 1414.500000 98707.0400 69.7823
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 28.000000 2000.3200 71.4400
TRAV-TRAVS-Travel by mile 448 33601.00000 14708.0600 0.4377
Subtotal (Total Children Is Unduplicated) 1403 46755.50000 772667.6600 16.5257
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Total 61541.250000 1370540.8000 22.2703
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Number of Children (Unduplicated) With at Least One Service 2290
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Center 09
Flag Claims Units Chgs Paid
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R 40 51.500000 2183.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 626 701.250000 27478.0000 0.0000
P 12912 30284.500000 688747.5300 689538.0400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 318 434.500000 24167.7500 0.0000
T 3 13.000000 481.0000 425.5000
6784 29691.000000 600889.5200 9.2500
Other 188 365.500000 26593.5000 0.0000
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Total 20871 61541.250000 1370540.8000 689972.7900