CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
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
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.00 53.10 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.00 44.15 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.00 54.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.00 87.16 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.00 113.12 28.28
Subtotal (Total Children Is Unduplicated) 5 23.00 351.53 15.28
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 36.00 900.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 82 610.25 30512.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 75 233.50 15849.98 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 2.00 108.64 54.32
PHY-97110-PT SESSION BY LICENSED PT 134 391.25 26558.05 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 136 345.50 23452.54 67.88
Subtotal (Total Children Is Unduplicated) 293 1618.50 97381.71 60.17
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Total 1641.50 97733.24 59.54
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Number of Children (Unduplicated) With at Least One Service 297
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Center 10
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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
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
802 1641.50 97733.24 0.00
Other 0 0.00 0.00 0.00
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Total 802 1641.50 97733.24 0.00