CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2008 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.00 37.00 37.00
Subtotal (Total Children Is Unduplicated) 1 1.00 37.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 61.00 61.00
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 42.00 42.00
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 50.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 6.00 450.00 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 2186.64 242.96
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.00 1105.43 100.49
Subtotal (Total Children Is Unduplicated) 26 37.00 4374.35 118.23
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 34.50 1725.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 22 117.25 9378.40 79.99
OCCT-97530HM-OT SESSION BY OT ASST 1 0.50 27.16 54.32
PHY-97110-PT SESSION BY LICENSED PT 10 50.25 4893.85 97.39
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 174.75 13123.71 75.10
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 337.00 168.50 0.50
Subtotal (Total Children Is Unduplicated) 65 714.25 29316.62 41.05
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Total 752.25 33727.97 44.84
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Number of Children (Unduplicated) With at Least One Service 79
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Center 07
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 24 386.00 2878.78 2878.78
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
177 366.25 30849.19 0.00
Other 0 0.00 0.00 0.00
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Total 201 752.25 33727.97 2878.78