CMS/EIP Fiscal Report Center: 54
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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 10.00 88.30 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 21.91 236.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.00 16.88 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 18 18.10 394.40 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 6 6.00 169.68 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.00 190.86 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 11.50 862.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 11.50 638.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 40.50 3037.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 22.13 1658.77 74.96
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.00 525.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 48.00 2664.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 25.13 1883.77 74.96
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 5.13 248.37 48.42
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 23 21.99 1065.90 48.47
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 3.07 148.71 48.44
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 194.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 36 35.49 1721.00 48.49
Subtotal (Total Children Is Unduplicated) 162 312.45 16655.11 53.30
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 5.25 262.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 56 66.00 3300.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 9 5.00 125.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 32 27.25 1362.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 1.75 43.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 6.25 312.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.75 18.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 73 85.00 4250.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.50 62.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 22 274.75 13737.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 120 1134.25 56712.50 50.00
INTR-INTR-INTERPRETER 11 126.25 6312.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 134 730.73 49572.92 67.84
PHY-97110-PT SESSION BY LICENSED PT 56 268.18 18182.75 67.80
PHY-97110HM-PT SESSION BY PT ASST 1 0.04 1.94 48.50
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 163 1089.22 73931.66 67.88
TRAN-TRAN-FAMILY TRANSPORTATION 2 210.00 178.50 0.85
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 617 161554 137349.76 0.85
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 4 39.00 1950.00 50.00
Subtotal (Total Children Is Unduplicated) 706 165626 367667.53 2.22
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Total 165938.62 384322.64 2.32
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Number of Children (Unduplicated) With at Least One Service 720
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Center 54
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 3320 160605.54 360443.86 360443.86
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
223 5333.08 23878.78 0.00
Other 0 0.00 0.00 0.00
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Total 3543 165938.62 384322.64 360443.86