CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 628 2028.25 74777.00 36.87
Subtotal (Total Children Is Unduplicated) 628 2028.25 74777.00 36.87
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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) 6 6.00 52.98 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 10.00 108.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.00 152.53 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.00 127.24 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.50 337.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.00 388.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 6.00 450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 31.50 2362.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 39.00 2164.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 49.50 3712.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 12.00 582.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 12.00 582.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 22 22.00 1067.00 48.50
Subtotal (Total Children Is Unduplicated) 129 228.50 13184.37 57.70
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 160 1122.75 56137.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 45 285.00 19145.71 67.18
OCCT-97530HM-OT SESSION BY OT ASST 18 176.75 9601.06 54.32
PHY-97110-PT SESSION BY LICENSED PT 42 237.25 16104.53 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 81 463.75 31428.44 67.77
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.50 46.20 13.20
Subtotal (Total Children Is Unduplicated) 260 2292.00 132613.44 57.86
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Total 4548.75 220574.81 48.49
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Number of Children (Unduplicated) With at Least One Service 661
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Center 54
Flag Claims Units Chgs Paid
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R 3 1.75 64.75 0.00
U 0 0.00 0.00 0.00
B 1103 937.25 44332.25 0.00
P 2517 1627.75 60014.00 60014.00
D 0 0.00 0.00 0.00
S 1 0.50 18.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
766 1980.00 116089.81 0.00
Other 2 1.50 55.50 0.00
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Total 4392 4548.75 220574.81 60014.00