CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Agency Filter:EXT
Payclass Filters:GR
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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 1.00 50.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 34 36.00 1700.00 47.22
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.00 48.50 48.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 1.24 60.00 48.39
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.00 518.94 47.18
Subtotal (Total Children Is Unduplicated) 52 59.24 2734.34 46.16
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 37 31.50 1575.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.75 37.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 2.50 125.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 0.75 18.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 3.50 175.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 21 141.66 7082.82 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 7.00 350.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 23 108.95 7393.09 67.86
PHY-97110-PT SESSION BY LICENSED PT 28 159.75 10843.83 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 462.37 31384.04 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 390 83884.0 41942.00 0.50
Subtotal (Total Children Is Unduplicated) 413 84804.7 101002.03 1.19
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Total 84863.97 103736.37 1.22
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Number of Children (Unduplicated) With at Least One Service 424
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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 544 27725.77 34231.94 34231.94
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
1081 57138.20 69504.43 0.00
Other 0 0.00 0.00 0.00
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Total 1625 84863.97 103736.37 34231.94