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:TPIN
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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.75 27.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 3.75 138.75 37.00
Subtotal (Total Children Is Unduplicated) 4 4.50 166.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 122 122.00 1077.26 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 117 117.00 1263.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 118 118.00 2571.22 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 11 11.00 311.08 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.50 187.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 130 194.50 14587.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 64 91.50 6862.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 59 92.50 6937.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.00 525.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 6 6.00 163.32 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 20 20.00 1145.40 57.27
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 213.38 53.35
Subtotal (Total Children Is Unduplicated) 182 792.00 36132.43 45.62
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.50 25.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.50 65.00 43.33
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 20.00 1000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 68 260.00 17648.80 67.88
OCCT-97530HM-OT SESSION BY OT ASST 5 7.50 407.40 54.32
PHY-97110-PT SESSION BY LICENSED PT 90 348.25 23639.21 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 27.16 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 163 567.25 38170.53 67.29
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 9.50 516.04 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 3 9.50 125.40 13.20
Subtotal (Total Children Is Unduplicated) 264 1225.50 81649.54 66.63
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Total 2022.00 117948.47 58.33
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Number of Children (Unduplicated) With at Least One Service 409
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Center 06
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 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
2392 2022.00 117948.47 0.00
Other 0 0.00 0.00 0.00
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Total 2392 2022.00 117948.47 0.00