CMS/EIP Fiscal Report Center: 10
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 1214 4622.00 170967.75 36.99
Subtotal (Total Children Is Unduplicated) 1214 4622.00 170967.75 36.99
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.38 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 45.00 3375.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 17.00 1275.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 14.50 1087.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 12.00 900.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 39.50 2192.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 137 219.50 16462.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 97 157.50 11812.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 76 119.00 8925.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 144 250.50 13902.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 101 124.50 9300.00 74.70
Subtotal (Total Children Is Unduplicated) 264 1007.00 69451.45 68.97
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 32.00 800.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 91 626.25 31312.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 91 280.00 19006.40 67.88
OCCT-97530HM-OT SESSION BY OT ASST 15 20.75 1127.14 54.32
PHY-97110-PT SESSION BY LICENSED PT 177 570.25 38708.57 67.88
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 167 544.00 36926.72 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 13.50 733.32 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 1.75 23.10 13.20
Subtotal (Total Children Is Unduplicated) 355 2090.50 128675.19 61.55
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Total 7719.50 369094.39 47.81
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Number of Children (Unduplicated) With at Least One Service 1232
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Center 10
Flag Claims Units Chgs Paid
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R 2 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 6921 4573.00 171133.25 0.00
P 760 1054.00 69601.25 69654.00
D 92 79.50 3738.50 3738.50
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1084 2011.25 124556.64 0.00
Other 0 0.00 0.00 0.00
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Total 8859 7719.50 369094.39 73392.50