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: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 748 2299.75 84952.00 36.94
Subtotal (Total Children Is Unduplicated) 748 2299.75 84952.00 36.94
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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 4 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 13.00 975.00 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 13 18.50 1387.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 30.50 2287.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 41 48.50 2691.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 61.00 4575.00 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 12 12.00 582.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 22.00 1067.00 48.50
Subtotal (Total Children Is Unduplicated) 160 257.00 15541.67 60.47
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 170 1179.00 58950.00 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) 272 2401.25 138864.40 57.83
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Total 4958.00 239358.07 48.28
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Number of Children (Unduplicated) With at Least One Service 795
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Center 54
Flag Claims Units Chgs Paid
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R 6 3.25 120.25 0.00
U 0 0.00 0.00 0.00
B 100 96.75 5360.01 0.00
P 3964 2755.50 110058.75 110049.50
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
788 2100.75 123726.56 0.00
Other 1 1.50 83.25 0.00
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Total 4860 4958.00 239358.07 110049.50