CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 1382 7822.25 289401.50 37.00
Subtotal (Total Children Is Unduplicated) 1382 7822.25 289401.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 364 375.00 3245.55 8.65
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 323 334.00 3580.32 10.72
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 311 323.00 6741.19 20.87
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 43 43.00 1208.41 28.10
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 11.50 862.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 17.00 1275.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.50 562.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 207 304.50 22837.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 178 263.00 19725.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 119 173.00 12975.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 16.00 1200.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 15 15.00 421.88 28.13
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 44 44.00 2677.40 60.85
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 3 3.00 54.51 18.17
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 5 5.00 172.50 34.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 13.00 630.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 21 24.00 1164.00 48.50
Subtotal (Total Children Is Unduplicated) 499 1983.50 79922.76 40.29
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 150 2461.25 123062.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 108 1562.00 106028.56 67.88
OCCT-97530HM-OT SESSION BY OT ASST 15 102.75 5581.38 54.32
PHY-97110-PT SESSION BY LICENSED PT 135 2140.75 145314.11 67.88
PHY-97110HM-PT SESSION BY PT ASST 10 35.00 1901.20 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 262 3350.00 227398.00 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 10.75 583.94 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 6 28.50 376.20 13.20
Subtotal (Total Children Is Unduplicated) 425 9691.00 610245.89 62.97
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Total 19496.75 979570.15 50.24
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Number of Children (Unduplicated) With at Least One Service 1386
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Center 06
Flag Claims Units Chgs Paid
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R 2 1.50 55.50 0.00
U 0 0.00 0.00 0.00
B 7227 4724.00 174766.25 1591.00
P 4380 2863.75 105958.75 105958.75
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
13542 11907.50 698789.65 9.25
Other 0 0.00 0.00 0.00
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Total 25151 19496.75 979570.15 107559.00