CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2008 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 756 1871.00 69205.25 36.99
Subtotal (Total Children Is Unduplicated) 756 1871.00 69205.25 36.99
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 36 36.00 317.88 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 34 34.00 367.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 33 33.00 719.07 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.50 187.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 79 121.50 9112.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 62 97.50 7312.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 56.00 4200.00 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 3 3.00 81.66 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 9 9.00 515.43 57.27
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 2 2.00 36.34 18.17
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.00 34.50 34.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 108 414.00 24113.08 58.24
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 83 632.00 31600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 44 303.25 20584.61 67.88
OCCT-97530HM-OT SESSION BY OT ASST 6 30.50 1656.76 54.32
PHY-97110-PT SESSION BY LICENSED PT 72 521.50 35399.42 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 6.50 353.08 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 110 706.25 47940.25 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.00 217.28 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.50 46.20 13.20
Subtotal (Total Children Is Unduplicated) 235 2207.50 137797.60 62.42
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Total 4492.50 231115.93 51.44
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Number of Children (Unduplicated) With at Least One Service 781
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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 2623 1712.75 63350.00 83.25
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
3249 2779.75 167765.93 0.00
Other 0 0.00 0.00 0.00
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Total 5872 4492.50 231115.93 83.25