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: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 813 2628.25 97245.25 37.00
Subtotal (Total Children Is Unduplicated) 813 2628.25 97245.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 44 44.00 388.52 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 44 44.00 475.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 42 42.00 915.18 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.00 113.12 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.00 900.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 11.00 825.00 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 128 188.00 14100.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 118 175.50 13162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 24.00 1800.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 11.00 629.97 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) 179 570.00 34045.21 59.73
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 120 759.50 37975.00 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 83 500.75 33977.35 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) 285 2233.25 136799.16 61.26
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Total 5431.50 268089.62 49.36
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Number of Children (Unduplicated) With at Least One Service 835
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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 1633 1196.00 44252.00 619.75
P 1540 1190.25 52475.25 52437.75
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
3836 3045.25 171362.37 0.00
Other 0 0.00 0.00 0.00
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Total 7009 5431.50 268089.62 53057.50