CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 06/30/2017 Date of Report:08/05/2017 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1599 9014.250000 332684.1900 36.9065
Subtotal (Total Children Is Unduplicated) 1599 9014.250000 332684.1900 36.9065
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.2600 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 49 96.500000 7237.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 78 158.500000 11887.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 48 88.000000 6600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 143 280.500000 15476.7500 55.1756
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 59 97.000000 7275.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 70.500000 5287.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 58.000000 4350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 431 742.000000 41125.5000 55.4252
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 491 889.500000 66675.0000 74.9578
WHEELO-97003TG-WHEELCHAIR EVAL/ FITTING BY LICENSED O 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 668 2487.500000 166226.6700 66.8248
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 8 17.000000 1246.4400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 22 77.000000 1925.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 978 13525.82500 676129.7500 49.9881
Subtotal (Total Children Is Unduplicated) 978 13619.82500 679301.1900 49.8759
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Total 25121.575000 1178212.0500 46.9004
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Number of Children (Unduplicated) With at Least One Service 1622
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Center 53
Flag Claims Units Chgs Paid
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R 22 22.000000 960.5000 592.0000
U 0 0.000000 0.0000 0.0000
B 940 852.500000 37700.5000 6003.2500
P 15487 14603.075000 658746.5000 658640.5000
D 0 0.000000 0.0000 0.0000
S 825 775.500000 28522.9400 28367.4400
H 0 0.000000 0.0000 0.0000
T 1 2.000000 20.0000 20.0000
8667 8862.250000 452090.3600 0.0000
Other 7 4.250000 171.2500 0.0000
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Total 25949 25121.575000 1178212.0500 693623.1900