CMS/EIP Fiscal Report Center: 10
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 1292 4775.00 176675.00 37.00
Subtotal (Total Children Is Unduplicated) 1292 4775.00 176675.00 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.38 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 28.00 2100.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 11.00 825.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 15.50 1162.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.00 450.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 32.00 1776.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 135 240.00 18000.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 74 134.00 10050.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 93 154.00 11550.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 156 293.50 16289.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 103 122.00 9150.00 75.00
Subtotal (Total Children Is Unduplicated) 265 1042.00 71443.27 68.56
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 3.00 142.20 47.40
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 49.00 1225.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 103 913.75 45687.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 103 394.25 26761.69 67.88
OCCT-97530HM-OT SESSION BY OT ASST 11 30.00 1629.60 54.32
PHY-97110-PT SESSION BY LICENSED PT 187 688.25 46718.41 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 182 583.00 39574.04 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 20.50 1113.56 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
Subtotal (Total Children Is Unduplicated) 381 2682.25 162858.60 60.72
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Total 8499.25 410976.87 48.35
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Number of Children (Unduplicated) With at Least One Service 1318
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Center 10
Flag Claims Units Chgs Paid
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R 19 9.25 342.25 0.00
U 0 0.00 0.00 0.00
B 5947 3990.25 158086.75 0.00
P 1502 1373.75 73417.44 73383.50
D 0 0.00 0.00 0.00
S 608 438.25 16215.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1312 2687.75 162915.18 0.00
Other 0 0.00 0.00 0.00
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Total 9388 8499.25 410976.87 73383.50