CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 ending 09/30/2018 Date of Report:11/06/2018 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.750000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1 0.750000 0.0000 0.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 12.6100 12.6100
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-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 25.3100 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 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 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 16.000000 1200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 60.000000 3330.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 53.000000 4012.5000 75.7075
Subtotal (Total Children Is Unduplicated) 64 178.000000 11877.2900 66.7263
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.000000 146.6400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 125 724.855800 36317.7900 50.1035
OCCT-97530-OT SESSION BY LICENSED OT 13 80.729560 5767.3196 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 8.000000 571.5200 71.4400
Subtotal (Total Children Is Unduplicated) 140 816.585360 42828.2696 52.4480
-----------------------------------------------------------------------------------------------------------------------
Total 995.335360 54705.5596 54.9619
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 179
-----------------------------------------------------------------------------------------------------------------------
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 42 31.444200 1572.2100 700.9800
D 36 39.000000 2098.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 12.500000 586.2900 586.2900
T 2 3.000000 161.0000 161.0000
473 626.391160 34594.8096 0.0000
Other 252 283.000000 15692.7500 0.0000
---------------------------------------------------------
Total 815 995.335360 54705.5596 1448.2700