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:TPIN
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 69 69.00 609.27 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 69 69.00 745.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 67 67.00 1459.93 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.50 487.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.00 600.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 169 251.00 18825.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 158 227.00 17025.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 37.00 2775.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 4 4.00 108.88 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 1 1.00 192.52 192.52
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 213 755.50 43631.34 57.75
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 16.00 800.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 56 197.25 16027.53 81.25
OCCT-97530HM-OT SESSION BY OT ASST 5 11.50 624.68 54.32
PHY-97110-PT SESSION BY LICENSED PT 51 203.25 15295.30 75.25
PHY-97110HM-PT SESSION BY PT ASST 7 12.00 848.81 70.73
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 159 618.00 45134.92 73.03
SPL-92508-GROUP SPL SESSION PER CHILD 10 11.00 365.63 33.24
Subtotal (Total Children Is Unduplicated) 235 1069.00 79096.87 73.99
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Total 1824.50 122728.21 67.27
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Number of Children (Unduplicated) With at Least One Service 408
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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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
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
2249 1824.50 122728.21 0.00
Other 0 0.00 0.00 0.00
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Total 2249 1824.50 122728.21 0.00