CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 902 2879.500000 106504.5000 36.9872
Subtotal (Total Children Is Unduplicated) 902 2879.500000 106504.5000 36.9872
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 46 46.000000 380.8800 8.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 46 46.000000 477.4800 10.3800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 46 46.000000 969.6800 21.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 54.3800 27.1900
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 122 184.500000 13837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 110 168.000000 12600.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 26.500000 1987.5000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 171.8100 57.2700
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 2.000000 97.0000 48.5000
Subtotal (Total Children Is Unduplicated) 140 539.000000 31674.7300 58.7657
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 197 1114.000000 55700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 157.750000 10708.0700 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 4 35.750000 1941.9400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 39 199.750000 13559.0300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 3 2.750000 149.3800 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 281.500000 19108.2200 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 6.000000 79.2000 13.2000
Subtotal (Total Children Is Unduplicated) 287 1797.500000 101245.8400 56.3259
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Total 5216.000000 239425.0700 45.9020
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Number of Children (Unduplicated) With at Least One Service 925
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Center 06
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2717 1974.500000 73056.5000 0.0000
P 1288 899.750000 33253.7500 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2495 2341.750000 133114.8200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6500 5216.000000 239425.0700 0.0000