CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 843 2812.75 104071.75 37.00
Subtotal (Total Children Is Unduplicated) 843 2812.75 104071.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 46 46.00 406.18 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 46 46.00 496.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 44 44.00 958.76 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.50 412.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 104 145.50 10912.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 77 112.50 8437.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.00 610.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.50 337.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 27.22 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.00 229.08 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 139 438.00 23817.35 54.38
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 128 772.00 38600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 22 142.25 9655.93 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 7.00 380.24 54.32
PHY-97110-PT SESSION BY LICENSED PT 76 371.50 25217.42 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 3.00 162.96 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 144 746.50 50605.04 67.79
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 286 2046.25 124674.39 60.93
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Total 5297.00 252563.49 47.68
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Number of Children (Unduplicated) With at Least One Service 860
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Center 06
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 1538 961.25 35566.25 129.50
P 2688 1758.25 65055.25 65055.25
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
2967 2577.50 151941.99 0.00
Other 0 0.00 0.00 0.00
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Total 7193 5297.00 252563.49 65184.75