CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 710 2327.75 86126.75 37.00
Subtotal (Total Children Is Unduplicated) 710 2327.75 86126.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 43 43.00 379.69 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 43 43.00 464.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 41 41.00 893.39 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.00 113.12 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 10.50 787.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.50 712.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 108 161.00 12075.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 98 150.00 11250.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.50 1687.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 572.70 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 155 507.00 29560.52 58.30
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 116 732.50 36625.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 61 407.75 27678.07 67.88
OCCT-97530HM-OT SESSION BY OT ASST 5 8.50 461.72 54.32
PHY-97110-PT SESSION BY LICENSED PT 81 489.75 33230.67 67.85
PHY-97110HM-PT SESSION BY PT ASST 6 14.50 787.64 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 123 526.00 35704.88 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 5 16.25 214.50 13.20
Subtotal (Total Children Is Unduplicated) 280 2195.25 134702.48 61.36
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Total 5030.00 250389.75 49.78
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Number of Children (Unduplicated) With at Least One Service 731
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Center 06
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 1434 1046.25 38711.25 582.75
P 1376 1065.50 46985.50 46948.00
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 0 0.00 0.00 0.00
3689 2918.25 164693.00 0.00
Other 0 0.00 0.00 0.00
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Total 6499 5030.00 250389.75 47530.75