CMS/EIP Fiscal Report Center: 54
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 815 2549.75 94072.50 36.89
Subtotal (Total Children Is Unduplicated) 815 2549.75 94072.50 36.89
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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) 11 11.00 97.13 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 11 12.00 129.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 9.00 196.11 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.00 190.86 31.81
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 9 11.50 862.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 11.50 862.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 26.00 1443.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 18.00 1350.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 29.00 2175.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 83.50 4634.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 76 104.00 7800.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 25 27.00 1309.50 48.50
Subtotal (Total Children Is Unduplicated) 174 366.00 21869.07 59.75
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 181 979.25 48950.00 49.99
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 41 157.25 10674.13 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 7.00 380.24 54.32
PHY-97110-PT SESSION BY LICENSED PT 42 142.25 9554.11 67.16
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 102 443.75 30121.75 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.50 190.12 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 270 1741.00 100098.15 57.49
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Total 4656.75 216039.72 46.39
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Number of Children (Unduplicated) With at Least One Service 840
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Center 54
Flag Claims Units Chgs Paid
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R 69 66.00 2904.50 0.00
U 0 0.00 0.00 0.00
B 2099 1661.00 70534.93 0.00
P 2352 1715.50 70483.61 70445.73
D 40 28.50 1463.48 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
500 1185.75 70653.20 0.00
Other 0 0.00 0.00 0.00
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Total 5060 4656.75 216039.72 70445.73