CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 338 834.25 30867.25 37.00
Subtotal (Total Children Is Unduplicated) 338 834.25 30867.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 8.00 444.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 47 91.29 6846.77 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 57.29 4296.77 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 96 185.00 10267.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 74.50 5587.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 130 454.58 29352.96 64.57
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 15.00 375.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 334 2032.50 101625.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 5 8.00 400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 17 79.50 5396.46 67.88
PHY-97110-PT SESSION BY LICENSED PT 21 126.75 8603.79 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 7 13.00 650.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 108.00 7331.04 67.88
Subtotal (Total Children Is Unduplicated) 353 2382.75 124381.29 52.20
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Total 3671.58 184601.50 50.28
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Number of Children (Unduplicated) With at Least One Service 503
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Center 53
Flag Claims Units Chgs Paid
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R 18 19.75 1016.50 0.00
U 0 0.00 0.00 0.00
B 582 515.00 20613.00 0.00
P 1141 1210.08 60446.29 60390.79
D 4 6.00 359.50 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
2040 1920.75 102166.21 800.00
Other 0 0.00 0.00 0.00
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Total 3785 3671.58 184601.50 61190.79