CMS/EIP Fiscal Report Center: 52
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 1 1.000000 45.0000 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 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 8.000000 450.0000 56.2500
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 4.000000 150.0000 37.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 38.000000 2850.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 55 119.500000 8212.5000 68.7238
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 18.000000 1200.0000 66.6667
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.000000 1110.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 41 82.000000 4551.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.0500 51.0250
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 22 23.000000 1100.0000 47.8261
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
SPCH-92610TLGT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUN 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 157 379.500000 23963.9000 63.1460
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 15 13.250000 662.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 67 84.750000 4237.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 61 62.500000 1562.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 33 42.500000 2125.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 77 139.250000 6962.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 9 4.750000 118.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 28 23.500000 1175.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 59 89.000000 4450.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 4 1.750000 43.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 8.000000 400.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 14 12.500000 625.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 4 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 6.500000 325.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 22 22.750000 1137.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 6 3.500000 87.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 127 336.500000 16825.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 157 573.500000 28675.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 286 799.000000 7990.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 28.000000 1643.1200 58.6829
OCCT-97530GT-OT SESSION BY LICENSED OT 19 65.750000 4482.8600 68.1804
OCCT-97530HM-OT SESSION BY OT ASST 7 12.000000 686.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 7 31.750000 1816.1000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 21 41.750000 2911.1800 69.7289
OCCT-97530TLGT-OT SESSION BY LICENSED OT 26 99.250000 7090.4200 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 8 28.000000 1601.6000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 3 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 20 46.500000 2839.7400 61.0697
PHY-97110GT-PT SESSION BY LICENSED PT 23 93.500000 5858.0800 62.6533
PHY-97110TL-PT SESSION BY LICENSED PT 25 61.500000 4393.5600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 19 75.250000 5375.8600 71.4400
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 1000.0000 500.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 113.000000 7929.8400 70.1756
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 72 393.000000 26004.1600 66.1683
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 32 75.500000 5393.7200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 27 112.250000 8019.1400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 10 8.750000 323.7500 37.0000
TRAV-TRAVS-Travel by mile 215 6843.000000 3044.5000 0.4449
Subtotal (Total Children Is Unduplicated) 477 10363.25000 168156.3300 16.2262
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Total 10742.750000 192120.2300 17.8837
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Number of Children (Unduplicated) With at Least One Service 520
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Center 52
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 1 0.750000 53.5800 98.3200
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 1791 8992.000000 86322.5000 86326.9500
939 1750.000000 105744.1500 92.5000
Other 0 0.000000 0.0000 0.0000
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Total 2731 10742.750000 192120.2300 86517.7700