CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.00 52.98 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 10.00 108.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.00 152.53 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.00 127.24 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 9.50 527.25 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 11.00 533.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 12.00 582.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 22 22.00 1067.00 48.50
Subtotal (Total Children Is Unduplicated) 67 101.50 4308.62 42.45
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 77 689.50 34475.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 45 285.00 19145.71 67.18
OCCT-97530HM-OT SESSION BY OT ASST 18 176.75 9601.06 54.32
PHY-97110-PT SESSION BY LICENSED PT 42 237.25 16104.53 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 81 463.75 31428.44 67.77
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.50 46.20 13.20
Subtotal (Total Children Is Unduplicated) 184 1855.75 110800.94 59.71
----------------------------------------------------------------------------------------------------------------
Total 1957.25 115109.56 58.81
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 211
----------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
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
736 1957.25 115109.56 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 736 1957.25 115109.56 0.00