CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 639 1743.50 64509.50 37.00
Subtotal (Total Children Is Unduplicated) 639 1743.50 64509.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 78 78.00 688.74 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 72 72.00 777.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 67 67.00 1459.93 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 9.00 254.52 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 63 91.00 6825.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 66.00 4950.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 54.50 4087.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.50 262.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 8 8.00 458.16 57.27
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 2 2.00 69.00 34.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 105 465.00 20548.89 44.19
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 76 546.00 27300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 60 386.50 26235.62 67.88
OCCT-97530HM-OT SESSION BY OT ASST 3 17.00 923.44 54.32
PHY-97110-PT SESSION BY LICENSED PT 69 421.25 28594.45 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 9.00 488.88 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 126 714.75 48517.23 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
Subtotal (Total Children Is Unduplicated) 238 2095.50 132072.82 63.03
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Total 4304.00 217131.21 50.45
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Number of Children (Unduplicated) With at Least One Service 664
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Center 06
Flag Claims Units Chgs Paid
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R 1 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 2568 1680.75 62187.75 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3054 2622.75 154924.96 0.00
Other 0 0.00 0.00 0.00
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Total 5623 4304.00 217131.21 0.00