CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 2.25 83.25 37.00
Subtotal (Total Children Is Unduplicated) 2 2.25 83.25 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
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.50 75.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 28.49 2136.93 75.01
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 13.91 1043.86 75.04
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.50 337.50 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 24.00 1937.50 80.73
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 261.88 52.38
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 3.83 185.79 48.51
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.00 291.00 48.50
Subtotal (Total Children Is Unduplicated) 48 91.23 6359.38 69.71
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 1.00 1.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 5.00 250.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 29 103.78 7046.48 67.90
OCCT-97530HM-OT SESSION BY OT ASST 6 41.00 2227.12 54.32
PHY-97110-PT SESSION BY LICENSED PT 13 48.12 3236.41 67.26
PHY-97110HM-PT SESSION BY PT ASST 8 22.57 1232.92 54.63
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 213.72 14507.54 67.88
Subtotal (Total Children Is Unduplicated) 92 443.19 28838.91 65.07
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Total 536.67 35281.54 65.74
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Number of Children (Unduplicated) With at Least One Service 117
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Center 55
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 1 1.00 67.88 67.88
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 1 1.50 250.00 0.00
T 0 0.00 0.00 0.00
746 534.17 34963.66 0.00
Other 0 0.00 0.00 0.00
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Total 748 536.67 35281.54 67.88