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: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 11 12.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 27 96.750000 3515.0000 36.3307
Subtotal (Total Children Is Unduplicated) 38 109.500000 3524.2500 32.1849
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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
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 17.500000 1312.5000 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 10 17.000000 1237.5000 72.7941
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 49.000000 2719.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 28.500000 2137.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 28.166667 2112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 104 197.500000 10950.2500 55.4443
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 121 209.741566 15843.0681 75.5361
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
Subtotal (Total Children Is Unduplicated) 191 611.908233 39883.8581 65.1795
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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 217 2372.771000 118668.5500 50.0126
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) 221 2409.771000 119883.1100 49.7488
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Total 3131.179233 163291.2181 52.1501
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Number of Children (Unduplicated) With at Least One Service 301
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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 140 143.505000 7272.6700 7272.6700
2456 2655.241033 139296.8881 3496.7500
Other 67 68.000000 3605.2500 0.0000
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Total 2943 3131.179233 163291.2181 21282.8300