CMS/EIP Fiscal Report Center: 10
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 1429 5043.50 186609.50 37.00
Subtotal (Total Children Is Unduplicated) 1429 5043.50 186609.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.18 10.59
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 37.50 2812.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 16.50 1237.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 14.50 1087.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 29.00 1609.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 154 262.00 19650.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 114 189.00 14175.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 78 126.50 9487.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 225 398.00 22089.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 126 143.50 10762.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 366 1245.50 84144.84 67.56
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 43.00 1075.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 147 1241.25 62062.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 101 428.50 29086.58 67.88
OCCT-97530HM-OT SESSION BY OT ASST 6 14.00 760.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 215 707.00 47991.16 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 182 587.75 39896.47 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 17 29.00 1575.28 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.00 26.40 13.20
Subtotal (Total Children Is Unduplicated) 454 3053.50 182528.19 59.78
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Total 9342.50 453282.53 48.52
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Number of Children (Unduplicated) With at Least One Service 1455
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Center 10
Flag Claims Units Chgs Paid
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R 3 1.50 55.50 0.00
U 0 0.00 0.00 0.00
B 1548 963.25 36104.00 138.75
P 7192 5246.25 231711.50 231267.01
D 0 0.00 0.00 0.00
S 78 54.00 1998.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1489 3077.50 183413.53 0.00
Other 0 0.00 0.00 0.00
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Total 10310 9342.50 453282.53 231405.76