CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 1440 4284.50 158480.25 36.99
Subtotal (Total Children Is Unduplicated) 1440 4284.50 158480.25 36.99
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 3.00 65.37 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.50 487.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 10.50 582.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 94 126.50 9487.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 13.00 955.00 73.46
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 133 179.00 9930.50 55.48
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 111 122.00 9150.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 238 475.50 31243.32 65.71
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.00 714.37 178.59
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 152 745.25 37212.50 49.93
OCCT-97530-OT SESSION BY LICENSED OT 5 9.75 661.83 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 6.00 325.92 54.32
PHY-97110-PT SESSION BY LICENSED PT 15 45.25 3071.57 67.88
PHY-97110HM-PT SESSION BY PT ASST 4 27.50 1493.80 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 424.00 28747.18 67.80
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.50 27.16 54.32
Subtotal (Total Children Is Unduplicated) 257 1262.25 72254.33 57.24
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Total 6022.25 261977.90 43.50
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Number of Children (Unduplicated) With at Least One Service 1495
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Center 01
Flag Claims Units Chgs Paid
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R 109 123.25 7777.00 0.00
U 0 0.00 0.00 0.00
B 2448 1728.50 66954.25 0.00
P 1568 1143.00 43760.25 43759.75
D 95 109.50 7773.50 0.00
S 1768 1384.00 51208.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
620 1233.00 66348.07 0.00
Other 213 301.00 18156.83 0.00
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Total 6821 6022.25 261977.90 43759.75