CMS/EIP Fiscal Report Center: 07
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 753 2070.25 76349.50 36.88
Subtotal (Total Children Is Unduplicated) 753 2070.25 76349.50 36.88
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 117.00 6493.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 94 185.50 13912.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 14.00 679.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 34 34.00 1700.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 143 369.00 23698.99 64.22
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 212 1168.00 58300.00 49.91
OCCT-97530-OT SESSION BY LICENSED OT 7 34.00 2307.92 67.88
PHY-97110-PT SESSION BY LICENSED PT 8 26.00 1730.94 66.57
PHY-97110HM-PT SESSION BY PT ASST 1 4.00 217.28 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 111.50 7568.50 67.88
Subtotal (Total Children Is Unduplicated) 234 1343.50 70124.64 52.20
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Total 3782.75 170173.13 44.99
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Number of Children (Unduplicated) With at Least One Service 795
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Center 07
Flag Claims Units Chgs Paid
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R 2 1.00 37.00 0.00
U 0 0.00 0.00 0.00
B 3035 1978.00 73866.00 0.00
P 106 198.50 14056.00 14056.00
D 0 0.00 0.00 0.00
S 218 147.00 5624.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
593 1458.25 76590.13 0.00
Other 0 0.00 0.00 0.00
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Total 3954 3782.75 170173.13 14056.00