CMS/EIP Fiscal Report Center: 10
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-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.38 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
Subtotal (Total Children Is Unduplicated) 2 6.00 90.52 15.09
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 3.00 142.20 47.40
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 49.00 1225.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 103 913.75 45687.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 103 394.25 26761.69 67.88
OCCT-97530HM-OT SESSION BY OT ASST 11 30.00 1629.60 54.32
PHY-97110-PT SESSION BY LICENSED PT 187 688.25 46718.41 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 182 583.00 39574.04 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 20.50 1113.56 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
Subtotal (Total Children Is Unduplicated) 381 2682.25 162858.60 60.72
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Total 2688.25 162949.12 60.62
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Number of Children (Unduplicated) With at Least One Service 382
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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 1 0.50 33.94 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
1312 2687.75 162915.18 0.00
Other 0 0.00 0.00 0.00
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Total 1313 2688.25 162949.12 0.00