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: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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 2.00 74.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 66.50 2312.50 34.77
Subtotal (Total Children Is Unduplicated) 26 69.00 2405.00 34.86
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 16.00 141.28 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 23.00 248.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 17.00 370.43 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 1.84 52.44 28.50
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 8.00 254.48 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 8.50 637.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 11.50 1078.13 93.75
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 12.50 937.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 38.49 3281.26 85.25
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.00 388.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 41.99 5062.54 120.57
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.00 905.00 69.62
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 15 13.43 621.00 46.24
Subtotal (Total Children Is Unduplicated) 111 230.75 14945.47 64.77
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.50 25.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 21 77.00 5752.84 74.71
OCCT-97530-OT SESSION BY LICENSED OT 60 264.62 17980.75 67.95
OCCT-97530HM-OT SESSION BY OT ASST 1 2.25 122.22 54.32
PHY-97110-PT SESSION BY LICENSED PT 35 138.59 9426.44 68.02
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 74 300.59 20492.49 68.17
Subtotal (Total Children Is Unduplicated) 135 783.80 53812.24 68.66
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Total 1083.55 71162.71 65.68
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Number of Children (Unduplicated) With at Least One Service 220
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Center 54
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 22 34.00 6528.66 3411.14
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
627 1049.55 64634.05 0.00
Other 0 0.00 0.00 0.00
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Total 649 1083.55 71162.71 3411.14