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: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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 15.50 967.50 62.42
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 2.76 160.50 58.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.00 630.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 615.94 47.38
Subtotal (Total Children Is Unduplicated) 56 68.26 3428.95 50.23
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 78.84 3942.18 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 7.75 387.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 32 145.05 9821.31 67.71
PHY-97110-PT SESSION BY LICENSED PT 42 179.75 12233.81 68.06
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.50 75.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 88 385.85 26192.23 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 7.50 99.00 13.20
Subtotal (Total Children Is Unduplicated) 142 806.24 52751.03 65.43
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Total 874.50 56179.98 64.24
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Number of Children (Unduplicated) With at Least One Service 167
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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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
451 874.50 56179.98 0.00
Other 0 0.00 0.00 0.00
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Total 451 874.50 56179.98 0.00