CMS/EIP Fiscal Report Center: 54
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 654 1978.75 73084.25 36.93
Subtotal (Total Children Is Unduplicated) 654 1978.75 73084.25 36.93
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.00 52.98 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 8.00 86.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.00 130.74 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 5 5.00 159.05 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 10.50 787.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.50 249.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 11.00 825.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 20.00 1500.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 26.50 1470.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 36.00 2700.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 22.00 1067.00 48.50
Subtotal (Total Children Is Unduplicated) 119 185.50 10634.67 57.33
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 169 1178.00 58900.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 1.00 50.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 48 249.75 16953.03 67.88
OCCT-97530HM-OT SESSION BY OT ASST 23 223.75 12154.10 54.32
PHY-97110-PT SESSION BY LICENSED PT 47 255.25 17326.37 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 94 492.50 33430.90 67.88
Subtotal (Total Children Is Unduplicated) 271 2400.25 138814.40 57.83
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Total 4564.50 222533.32 48.75
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Number of Children (Unduplicated) With at Least One Service 700
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Center 54
Flag Claims Units Chgs Paid
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R 5 2.75 101.75 0.00
U 0 0.00 0.00 0.00
B 94 89.00 4788.26 0.00
P 3508 2390.75 95210.00 95200.75
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 1 0.25 9.25 0.00
771 2081.75 122424.06 0.00
Other 0 0.00 0.00 0.00
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Total 4379 4564.50 222533.32 95200.75