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: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 718 2350.25 86663.25 36.87
Subtotal (Total Children Is Unduplicated) 718 2350.25 86663.25 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 3 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 9.00 675.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 7.50 562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 10.00 555.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 13.00 975.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 51.50 3862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 61.00 3385.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 66.00 4950.00 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) 169 304.50 18396.87 60.42
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 161 1125.75 56287.50 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) 261 2295.00 132763.44 57.85
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Total 4949.75 237823.56 48.05
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Number of Children (Unduplicated) With at Least One Service 753
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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 1241 1058.25 50598.00 0.00
P 2875 1898.50 70369.75 70369.75
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
777 1989.25 116717.06 0.00
Other 2 1.50 55.50 0.00
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Total 4899 4949.75 237823.56 70369.75