CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 1004 3891.00 143967.00 37.00
Subtotal (Total Children Is Unduplicated) 1004 3891.00 143967.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.00 53.10 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.00 44.15 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.00 54.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.00 87.16 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.00 113.12 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 29.00 2175.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 11.50 862.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 12.50 937.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.00 750.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 106 189.50 14212.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 58 105.00 7875.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 70 113.50 8512.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 83.00 4606.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 72 95.00 7125.00 75.00
Subtotal (Total Children Is Unduplicated) 172 688.00 48296.03 70.20
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 36.00 900.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 85 665.25 33262.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 75 233.50 15849.98 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 2.00 108.64 54.32
PHY-97110-PT SESSION BY LICENSED PT 134 391.25 26558.05 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 136 345.50 23452.54 67.88
Subtotal (Total Children Is Unduplicated) 295 1673.50 100131.71 59.83
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Total 6252.50 292394.74 46.76
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Number of Children (Unduplicated) With at Least One Service 1030
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Center 10
Flag Claims Units Chgs Paid
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R 5 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 6136 3793.75 141057.75 0.00
P 485 711.25 49681.75 49722.50
D 16 9.25 342.25 342.25
S 156 95.00 3515.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
802 1641.50 97733.24 0.00
Other 0 0.00 0.00 0.00
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Total 7600 6252.50 292394.74 50064.75