CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 4 8.000000 400.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 37 74.000000 5550.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 32.000000 2400.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 43 84.500000 6337.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 29 57.000000 3163.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 114 293.000000 20488.5000 69.9266
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 3242.0000 1621.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 77 127.500000 6375.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 27 54.000000 2700.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 75 93.250000 2331.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 11 13.000000 650.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 3 7.000000 350.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 24.000000 1200.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 4 3.000000 150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 11.000000 550.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 4 4.000000 200.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 317 1958.500000 94915.1700 48.4632
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 17 41.000000 2050.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 42 246.000000 2220.0000 9.0244
OCCT-97530-OT SESSION BY LICENSED OT 83 497.500000 35541.4000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 12.000000 857.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 67 433.250000 30379.8600 70.1209
PHY-97110GT-PT SESSION BY LICENSED PT 7 37.000000 2643.2800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 199 1422.000000 97398.8000 68.4942
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 10.000000 714.4000 71.4400
TRAV-TRAVS-Travel by mile 912 87495.00000 37966.5100 0.4339
Subtotal (Total Children Is Unduplicated) 1086 92495.50000 322609.9500 3.4878
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Total 92788.500000 343098.4500 3.6976
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Number of Children (Unduplicated) With at Least One Service 1148
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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 3870 86510.500000 321784.3500 321784.3500
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 205 6266.000000 20236.1000 20236.1000
0 0.000000 0.0000 0.0000
Other 7 12.000000 1078.0000 0.0000
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Total 4082 92788.500000 343098.4500 342020.4500