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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1760 9869.500000 364189.6900 36.9005
Subtotal (Total Children Is Unduplicated) 1760 9869.500000 364189.6900 36.9005
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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 50 98.500000 7387.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 79 160.000000 12000.0000 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 57 101.500000 7612.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 157 302.000000 16670.0000 55.1987
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 81 128.500000 9637.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 40 72.000000 5400.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 46 71.500000 5362.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 535 901.500000 49977.7500 55.4384
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 609 1083.000000 81187.5000 74.9654
WHEELO-97003TG-WHEELCHAIR EVAL/ FITTING BY LICENSED O 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 815 2925.500000 195547.1700 66.8423
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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 979 13538.82500 676779.7500 49.9881
Subtotal (Total Children Is Unduplicated) 979 13632.82500 679951.1900 49.8760
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Total 26427.825000 1239688.0500 46.9084
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Number of Children (Unduplicated) With at Least One Service 1783
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Center 53
Flag Claims Units Chgs Paid
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R 30 29.250000 1228.7500 721.5000
U 0 0.000000 0.0000 0.0000
B 1029 944.500000 42270.5000 6456.5000
P 16403 15630.575000 705817.7500 705711.7500
D 0 0.000000 0.0000 0.0000
S 888 842.750000 30983.4400 30772.4400
H 0 0.000000 0.0000 0.0000
T 1 2.000000 20.0000 20.0000
8749 8974.500000 459196.3600 0.0000
Other 7 4.250000 171.2500 0.0000
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Total 27107 26427.825000 1239688.0500 743682.1900