CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 824 2529.25 93582.25 37.00
Subtotal (Total Children Is Unduplicated) 824 2529.25 93582.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 29 30.00 264.90 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 27 28.00 302.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 26 27.00 588.33 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 132.00 9900.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 90 119.50 8962.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.00 388.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.00 525.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 14 14.00 801.78 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 148 375.50 22284.69 59.35
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 119 731.00 36550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 32 210.50 14288.74 67.88
OCCT-97530HM-OT SESSION BY OT ASST 4 9.50 516.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 65 324.50 21964.68 67.69
PHY-97110HM-PT SESSION BY PT ASST 3 11.50 624.68 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 132 786.75 53404.59 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 4 6.00 79.20 13.20
Subtotal (Total Children Is Unduplicated) 275 2079.75 127427.93 61.27
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Total 4984.50 243294.87 48.81
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Number of Children (Unduplicated) With at Least One Service 845
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Center 06
Flag Claims Units Chgs Paid
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R 25 14.75 545.75 0.00
U 0 0.00 0.00 0.00
B 165 105.00 3885.00 434.75
P 3484 2242.75 83418.75 83418.75
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 0 0.00 0.00 0.00
3059 2622.00 155445.37 0.00
Other 0 0.00 0.00 0.00
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Total 6733 4984.50 243294.87 83853.50