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:TPIN
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 1.09 52.99 48.61
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-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.00 111.00 55.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.83 150.00 81.97
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 10 16.72 928.44 55.53
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 11.64 873.27 75.02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.27 394.90 74.93
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 23.89 1326.17 55.51
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.96 372.29 75.06
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 10.00 485.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 17.00 824.50 48.50
Subtotal (Total Children Is Unduplicated) 40 110.40 6164.42 55.84
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 12.00 600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 21 95.25 6466.50 67.89
OCCT-97530HM-OT SESSION BY OT ASST 1 0.50 27.16 54.32
PHY-97110-PT SESSION BY LICENSED PT 14 84.25 5718.89 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 129.42 8783.47 67.87
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.00 39.60 13.20
Subtotal (Total Children Is Unduplicated) 41 325.42 21689.94 66.65
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Total 435.82 27854.36 63.91
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Number of Children (Unduplicated) With at Least One Service 70
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Center 53
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 27 29.78 1869.06 1920.88
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
617 406.04 25985.30 0.00
Other 0 0.00 0.00 0.00
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Total 644 435.82 27854.36 1920.88