CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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
CASE-CASE-NON-TCM CASE MANAGEMENT 3 4.750000 175.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 23.500000 869.5000 37.0000
Subtotal (Total Children Is Unduplicated) 17 28.250000 1045.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 16.5200 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 18.1200 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 50.6200 25.3100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 24.000000 1800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.000000 975.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 43.500000 2414.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 43.500000 3262.5000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 57 166.000000 11086.3100 66.7850
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 0.750000 37.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 1.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 125 691.128600 34568.9300 50.0181
OCCT-97530-OT SESSION BY LICENSED OT 11 65.000000 4643.6000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 17.000000 1214.4800 71.4400
Subtotal (Total Children Is Unduplicated) 139 775.378600 40464.5100 52.1868
-----------------------------------------------------------------------------------------------------------------------
Total 969.628600 52596.0700 54.2435
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 171
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 65 71.728600 3956.4300 1569.5300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 72 72.250000 4538.1000 4538.1000
T 29 31.500000 1716.0400 1716.0400
679 726.650000 38706.5000 0.0000
Other 61 67.500000 3679.0000 0.0000
---------------------------------------------------------
Total 906 969.628600 52596.0700 7823.6700