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
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 1915 5527.500000 204499.0000 36.9967
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 807 3033.750000 112239.5000 36.9970
Subtotal (Total Children Is Unduplicated) 1997 8561.750000 316738.5000 36.9946
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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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
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 3 5.000000 375.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 24 42.500000 3187.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 19 38.500000 2887.5000 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 57 110.000000 8250.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 45 84.500000 4689.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 77.000000 3850.0000 50.0000
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 125 382.500000 24925.1500 65.1638
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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 79 147.000000 7350.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 40 69.750000 3487.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 148 192.500000 4812.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 8 12.000000 600.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 7 10.000000 500.0000 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 16 19.000000 950.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 6 7.000000 350.0000 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 183 982.500000 49125.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 231 1319.500000 65575.0000 49.6969
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 65 370.500000 26468.5200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 42 199.750000 14270.1400 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 113 685.250000 48954.2600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 434 28443.00000 12459.2800 0.4380
Subtotal (Total Children Is Unduplicated) 991 34105.00000 341327.6600 10.0081
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Total 43049.250000 682991.3100 15.8653
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Number of Children (Unduplicated) With at Least One Service 2087
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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 8321 20570.000000 432277.8100 432277.8100
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
4820 22457.250000 249141.5000 9.2500
Other 11 22.000000 1572.0000 0.0000
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Total 13152 43049.250000 682991.3100 432287.0600