CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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-92555-SPEECH AUD THRESHOLD (DETECTION) 2 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 3.00 65.37 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
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 20 31.00 2325.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 11.50 842.50 73.26
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 40.00 2216.00 55.40
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 49 97.50 5796.07 59.45
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.00 714.37 178.59
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 138 677.50 33825.00 49.93
OCCT-97530-OT SESSION BY LICENSED OT 5 9.75 661.83 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 6.00 325.92 54.32
PHY-97110-PT SESSION BY LICENSED PT 15 45.25 3071.57 67.88
PHY-97110HM-PT SESSION BY PT ASST 4 27.50 1493.80 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 424.00 28747.18 67.80
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.50 27.16 54.32
Subtotal (Total Children Is Unduplicated) 246 1194.50 68866.83 57.65
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Total 1292.00 74662.90 57.79
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Number of Children (Unduplicated) With at Least One Service 288
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Center 01
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
370 1007.75 57455.82 0.00
Other 200 284.25 17207.08 0.00
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Total 570 1292.00 74662.90 0.00