CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 06/30/2018 Date of Report:08/10/2018 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 8 37.250000 1378.2500 37.0000
Subtotal (Total Children Is Unduplicated) 8 37.250000 1378.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 33.0400 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 27.1800 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 126.5500 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 37.1000 18.5500
EXIT-EXIT-EXIT ASSESSMENT 1 1.250000 62.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 30.000000 2250.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 42.000000 3150.0000 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 6 9.009777 713.2333 79.1621
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 20.000000 1110.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 61.000000 4575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 36.000000 2700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 16.500000 1237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 124 199.175878 11048.7613 55.4724
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 108 186.499970 13949.9978 74.7989
NURS-T1001-NURSING ASSESSMENT 1 1.000000 50.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 194 618.935625 41234.4124 66.6215
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 4.000000 293.2800 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 229 2309.353200 115480.1600 50.0054
INTR-T1013-INTERPRETER 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 2.000000 20.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 183.423178 13103.7514 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 21.000000 1500.2400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 67.000000 4786.4800 71.4400
Subtotal (Total Children Is Unduplicated) 243 2596.776378 135580.4714 52.2111
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Total 3252.962003 178193.1338 54.7787
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Number of Children (Unduplicated) With at Least One Service 309
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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 380 391.574310 20993.0430 8719.7700
D 4 6.000000 395.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 312 319.000000 18232.9700 18232.9700
T 125 129.189299 7974.8761 7974.8800
1870 1962.948394 104587.6147 0.0000
Other 355 444.250000 26008.8800 0.0000
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Total 3046 3252.962003 178193.1338 34927.6200