CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
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
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 1 1.00 21.34 21.34
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.25 62.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 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 46 72.50 5242.50 72.31
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.50 637.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 8.26 573.00 69.37
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 54.50 3024.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 13.50 1012.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 15.00 727.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 28 28.00 1343.44 47.98
Subtotal (Total Children Is Unduplicated) 117 227.51 13712.70 60.27
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EI Services,Class #03
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 12.50 625.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 190.34 9517.18 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 7.75 387.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 41 198.30 13435.92 67.76
PHY-97110-PT SESSION BY LICENSED PT 44 184.25 12539.27 68.06
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 120 528.85 35899.07 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 7.50 99.00 13.20
Subtotal (Total Children Is Unduplicated) 184 1131.99 72627.94 64.16
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Total 1359.50 86340.64 63.51
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Number of Children (Unduplicated) With at Least One Service 241
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Center 52
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 78 143.50 9261.49 0.00
T 0 0.00 0.00 0.00
632 1216.00 77079.15 0.00
Other 0 0.00 0.00 0.00
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Total 710 1359.50 86340.64 0.00