CMS/EIP Fiscal Report Center: 54
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 708 2236.00 82038.25 36.69
Subtotal (Total Children Is Unduplicated) 708 2236.00 82038.25 36.69
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 2.00 250.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.50 262.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 17.00 1275.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 22.00 1612.50 73.30
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 10.50 582.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 7.50 562.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 45.00 3375.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 6.50 487.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 34 41.00 2275.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 65.00 4875.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 18 18.00 873.00 48.50
Subtotal (Total Children Is Unduplicated) 156 262.00 17380.21 66.34
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 175 986.50 49325.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 5.00 250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 32 163.00 11064.44 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 36 146.25 9927.45 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 93 393.00 26676.84 67.88
Subtotal (Total Children Is Unduplicated) 267 1697.75 97456.69 57.40
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Total 4195.75 196875.15 46.92
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Number of Children (Unduplicated) With at Least One Service 747
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Center 54
Flag Claims Units Chgs Paid
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R 15 10.50 379.25 0.00
U 0 0.00 0.00 0.00
B 1143 705.75 26199.50 0.00
P 2271 1493.25 54931.50 92185.58
D 2 0.50 18.50 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
1117 1985.75 115346.40 0.00
Other 0 0.00 0.00 0.00
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Total 4548 4195.75 196875.15 92185.58