CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 Page: 1
List order: No List
Payclass Filters:TPIN
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 1 0.250000 9.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 4.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 29.250000 1017.5000 34.7863
Subtotal (Total Children Is Unduplicated) 16 34.250000 1026.7500 29.9781
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 12.6100 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 16.5200 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 75.9300 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 375.0000 68.1818
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 21.500000 1193.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 43.000000 2375.5000 55.2442
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 69.748999 5268.6256 75.5369
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
Subtotal (Total Children Is Unduplicated) 54 186.248999 12097.5456 64.9536
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 5.000000 366.6000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 11.000000 275.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 145 825.500000 41237.5000 49.9546
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 146 844.500000 41997.1000 49.7301
-----------------------------------------------------------------------------------------------------------------------
Total 1064.998999 55121.3956 51.7572
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 173
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 42 39.450000 1923.7500 1188.7500
D 10 12.000000 661.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 70 71.649800 3653.9800 3653.9800
849 914.649199 47470.1656 0.0000
Other 29 27.250000 1412.5000 0.0000
---------------------------------------------------------
Total 1000 1064.998999 55121.3956 4842.7300