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: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 923 2824.75 104515.75 37.00
Subtotal (Total Children Is Unduplicated) 923 2824.75 104515.75 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 112 157.00 11775.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 114 148.00 11100.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 10.50 582.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.50 637.50 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) 177 434.00 26603.94 61.30
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 121 739.00 36950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 33 211.50 14356.62 67.88
OCCT-97530HM-OT SESSION BY OT ASST 4 9.50 516.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 66 327.00 22134.38 67.69
PHY-97110HM-PT SESSION BY PT ASST 3 11.50 624.68 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 135 795.25 53981.57 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 4 6.00 79.20 13.20
Subtotal (Total Children Is Unduplicated) 282 2099.75 128642.49 61.27
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Total 5358.50 259762.18 48.48
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Number of Children (Unduplicated) With at Least One Service 944
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Center 06
Flag Claims Units Chgs Paid
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R 26 15.25 564.25 0.00
U 0 0.00 0.00 0.00
B 192 121.50 4495.50 434.75
P 3893 2502.00 93087.00 93087.00
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
3161 2719.75 161615.43 225.00
Other 0 0.00 0.00 0.00
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Total 7272 5358.50 259762.18 93746.75