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: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 0.50 18.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 6.75 249.75 37.00
Subtotal (Total Children Is Unduplicated) 4 7.25 268.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 46 46.00 406.18 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 45 45.00 486.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 45 45.00 980.55 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.50 712.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.00 450.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 132 205.00 15375.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 85 128.50 9637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 64 108.00 8100.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.50 412.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.00 81.66 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 11.00 629.97 57.27
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 4 4.00 138.00 34.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 162 625.00 37914.86 60.66
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 30.00 30.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 4.50 225.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 25.00 1250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 54 193.00 13100.84 67.88
OCCT-97530HM-OT SESSION BY OT ASST 6 5.00 271.60 54.32
PHY-97110-PT SESSION BY LICENSED PT 81 330.50 22434.34 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 33.94 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 148 600.75 40778.91 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 72.00 36.00 0.50
Subtotal (Total Children Is Unduplicated) 244 1232.25 78160.63 63.43
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Total 1864.50 116343.74 62.40
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Number of Children (Unduplicated) With at Least One Service 354
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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
2181 1864.50 116343.74 0.00
Other 0 0.00 0.00 0.00
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Total 2181 1864.50 116343.74 0.00