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:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 11 12.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 24 84.750000 3080.2500 36.3451
Subtotal (Total Children Is Unduplicated) 35 97.500000 3089.5000 31.6872
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 23.0300 11.5150
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 42.2800 8.4560
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 17.1200 8.5600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.000000 199.0100 24.8763
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 37.1000 18.5500
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 15.500000 1162.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 25.500000 1912.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 487.5000 69.6429
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 40.500000 2247.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 25.500000 1912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 22.166667 1662.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 74 151.500000 8397.2500 55.4274
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 90 159.741566 12018.0681 75.2344
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
Subtotal (Total Children Is Unduplicated) 145 482.908233 31246.6081 64.7051
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 8.000000 586.5600 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 14.000000 350.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 216 2354.771000 117768.5500 50.0127
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10 11.000000 110.0000 10.0000
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) 220 2391.771000 118983.1100 49.7469
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Total 2972.179233 153319.2181 51.5848
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Number of Children (Unduplicated) With at Least One Service 254
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Center 53
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 225 206.130000 10082.0000 8985.7500
D 24 27.750000 1506.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 31 30.553200 1527.6600 1527.6600
T 137 139.505000 6972.6700 6972.6700
2348 2503.241033 129858.1381 3271.7500
Other 65 65.000000 3372.0000 0.0000
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Total 2830 2972.179233 153319.2181 20757.8300