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:Program Patients
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 761 2006.50 74240.50 37.00
Subtotal (Total Children Is Unduplicated) 761 2006.50 74240.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 86 86.00 759.38 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 80 80.00 864.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 74 74.00 1612.46 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 13 13.00 367.64 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 74 103.00 7725.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 73.50 5512.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 63.50 4762.50 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 12 12.00 687.24 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) 121 524.50 23338.16 44.50
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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 4626.50 229651.48 49.64
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Number of Children (Unduplicated) With at Least One Service 786
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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 2972 1940.50 71798.50 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
3114 2685.50 157834.48 0.00
Other 0 0.00 0.00 0.00
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Total 6087 4626.50 229651.48 0.00