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:TPIN
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
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 10 10.00 88.30 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 15 15.00 162.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 14 14.00 305.06 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.00 190.86 31.81
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 1 0.66 50.00 75.76
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.66 50.00 75.76
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 0.91 69.00 75.82
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 0.91 69.00 75.82
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 4.69 227.94 48.60
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 48 87.33 2869.35 32.86
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.25 62.50 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 1.75 87.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.00 100.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 24.00 1200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 69 369.17 24994.50 67.70
OCCT-97530HM-OT SESSION BY OT ASST 8 36.75 1996.26 54.32
PHY-97110-PT SESSION BY LICENSED PT 37 177.57 12067.58 67.96
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 76 337.47 22914.98 67.90
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 67.00 36.38 0.54
Subtotal (Total Children Is Unduplicated) 138 1017.96 63484.70 62.36
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Total 1105.29 66354.05 60.03
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Number of Children (Unduplicated) With at Least One Service 155
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Center 54
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
521 1105.29 66354.05 0.00
Other 0 0.00 0.00 0.00
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Total 521 1105.29 66354.05 0.00