CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 16 29.000000 1073.0000 37.0000
Subtotal (Total Children Is Unduplicated) 16 29.000000 1073.0000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 6.000000 306.3000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 25 25.000000 1276.2500 51.0500
Subtotal (Total Children Is Unduplicated) 45 61.000000 3441.7500 56.4221
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 202 1423.000000 71150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 70.363400 5026.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 12.000000 686.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 38 180.500000 12894.9200 71.4400
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 264.000000 18860.1600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 171.6000 57.2000
Subtotal (Total Children Is Unduplicated) 276 1954.863400 109035.8400 55.7767
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Total 2044.863400 113550.5900 55.5297
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Number of Children (Unduplicated) With at Least One Service 298
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Center 57
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 20 10.863400 755.6900 755.6900
D 0 0.000000 0.0000 0.0000
S 24 14.000000 915.4500 915.4500
H 0 0.000000 0.0000 0.0000
T 429 1393.500000 71521.2900 71521.2900
275 626.500000 40358.1600 38828.4100
Other 0 0.000000 0.0000 0.0000
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Total 748 2044.863400 113550.5900 112020.8400