CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 770 2362.00 87394.00 37.00
Subtotal (Total Children Is Unduplicated) 770 2362.00 87394.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 46 47.00 415.01 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 45 46.00 496.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 43 44.00 958.76 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 141.40 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.50 562.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.50 562.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 102 158.00 11850.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 98 147.50 11062.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.00 525.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.00 286.35 57.27
MED-99212-OUTPATIENT VISIT, EST, 10 MINS 1 1.00 18.17 18.17
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 436.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 141 499.50 28000.43 56.06
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 91 626.00 31300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 54 333.25 22621.01 67.88
OCCT-97530HM-OT SESSION BY OT ASST 3 12.00 651.84 54.32
PHY-97110-PT SESSION BY LICENSED PT 76 455.50 30919.34 67.88
PHY-97110HM-PT SESSION BY PT ASST 3 9.50 516.04 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 110 625.00 42391.06 67.83
SPL-92508-GROUP SPL SESSION PER CHILD 6 13.50 178.20 13.20
Subtotal (Total Children Is Unduplicated) 248 2074.75 128577.49 61.97
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Total 4936.25 243971.92 49.42
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Number of Children (Unduplicated) With at Least One Service 790
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Center 06
Flag Claims Units Chgs Paid
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R 8 4.00 148.00 111.00
U 0 0.00 0.00 0.00
B 2096 1458.00 53946.00 0.00
P 877 578.00 21386.00 21386.00
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 1 0.25 9.25 0.00
3513 2896.00 168482.67 0.00
Other 0 0.00 0.00 0.00
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Total 6495 4936.25 243971.92 21497.00