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: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 927 3059.00 113183.00 37.00
Subtotal (Total Children Is Unduplicated) 927 3059.00 113183.00 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 6 8.50 637.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.00 600.00 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 112 156.00 11700.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 83 120.00 9000.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.50 693.75 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 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 152 465.50 25797.60 55.42
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 129 778.00 38900.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 24 150.25 10198.97 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 7.00 380.24 54.32
PHY-97110-PT SESSION BY LICENSED PT 78 374.00 25387.12 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) 290 2062.75 125687.13 60.93
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Total 5587.25 264667.73 47.37
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Number of Children (Unduplicated) With at Least One Service 945
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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 1646 1033.50 38239.50 231.25
P 2932 1922.25 71123.25 71123.25
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
3024 2631.50 155304.98 0.00
Other 0 0.00 0.00 0.00
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Total 7602 5587.25 264667.73 71354.50