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: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 1123 4275.50 158193.50 37.00
Subtotal (Total Children Is Unduplicated) 1123 4275.50 158193.50 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 22 34.50 2587.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 16.50 1237.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 16.00 1200.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.00 900.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 20.00 1110.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 144 246.00 18450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 85 143.50 10762.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 88 139.00 10425.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 71 114.00 6327.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 91 124.00 9300.00 75.00
Subtotal (Total Children Is Unduplicated) 232 888.50 62651.03 70.51
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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 6837.50 320976.24 46.94
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Number of Children (Unduplicated) With at Least One Service 1150
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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 6561 4180.50 155745.50 0.00
P 614 899.75 63214.75 63255.50
D 18 10.25 379.25 379.25
S 168 103.75 3838.75 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 8168 6837.50 320976.24 63634.75