CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 932 3248.75 120203.75 37.00
Subtotal (Total Children Is Unduplicated) 932 3248.75 120203.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 47 47.00 415.01 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 48 48.00 518.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 45 45.00 980.55 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
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 3 5.00 375.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 93 127.00 9525.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 112 165.00 12375.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.50 638.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 25.50 1912.50 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 2 2.00 54.44 27.22
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 10 10.00 572.70 57.27
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 165 502.50 28186.63 56.09
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 136 839.50 41975.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 31 142.00 9638.96 67.88
PHY-97110-PT SESSION BY LICENSED PT 73 366.25 24861.05 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 5.00 271.60 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 138 689.25 46786.29 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 3 14.50 191.40 13.20
Subtotal (Total Children Is Unduplicated) 302 2056.50 123724.30 60.16
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Total 5807.75 272114.68 46.85
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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 4207 2787.75 103146.75 18.50
P 486 317.75 11756.75 11756.75
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
3103 2702.25 157211.18 0.00
Other 0 0.00 0.00 0.00
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Total 7796 5807.75 272114.68 11775.25