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:TPIN
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 3 5.75 212.75 37.00
Subtotal (Total Children Is Unduplicated) 3 5.75 212.75 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) 19 19.00 167.77 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 20.09 217.00 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.00 16.88 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 25 24.90 542.57 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 11 11.00 349.91 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.50 262.50 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 5 7.50 815.63 108.75
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 23.50 1762.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 13.37 1003.73 75.07
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 106.00 5883.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 40.87 5194.40 127.10
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 3.87 188.13 48.61
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 2.01 98.10 48.81
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 4.93 239.29 48.54
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 5.51 267.50 48.55
Subtotal (Total Children Is Unduplicated) 109 306.05 17909.97 58.52
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 1.00 50.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.00 25.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 0.50 25.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 1.75 87.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 2.50 125.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 30 137.75 7239.96 52.56
OCCT-97530-OT SESSION BY LICENSED OT 60 193.77 13181.62 68.03
OCCT-97530HM-OT SESSION BY OT ASST 12 86.25 4685.10 54.32
PHY-97110-PT SESSION BY LICENSED PT 42 182.57 12426.32 68.06
PHY-97110HM-PT SESSION BY PT ASST 1 0.46 32.00 69.57
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 358.03 24867.68 69.46
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 165.00 140.25 0.85
Subtotal (Total Children Is Unduplicated) 167 1131.08 62897.93 55.61
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Total 1442.88 81020.65 56.15
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Number of Children (Unduplicated) With at Least One Service 234
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Center 54
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 25 26.50 4358.76 2299.89
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
694 1416.38 76661.89 0.00
Other 0 0.00 0.00 0.00
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Total 719 1442.88 81020.65 2299.89