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: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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.25 9.25 37.00
Subtotal (Total Children Is Unduplicated) 1 0.25 9.25 37.00
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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) 6 6.00 52.98 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 8.00 86.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.00 130.74 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 5 5.00 159.05 31.81
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 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 11.00 825.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 7.50 416.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 3.50 262.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 22.00 1067.00 48.50
Subtotal (Total Children Is Unduplicated) 64 97.00 4385.92 45.22
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 98 752.00 37600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 47 247.75 16817.27 67.88
OCCT-97530HM-OT SESSION BY OT ASST 23 223.75 12154.10 54.32
PHY-97110-PT SESSION BY LICENSED PT 47 255.25 17326.37 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 94 492.50 33430.90 67.88
Subtotal (Total Children Is Unduplicated) 211 1971.25 117328.64 59.52
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Total 2068.50 121723.81 58.85
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Number of Children (Unduplicated) With at Least One Service 232
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Center 54
Flag Claims Units Chgs Paid
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R 1 0.25 9.25 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
755 2068.25 121714.56 0.00
Other 0 0.00 0.00 0.00
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Total 756 2068.50 121723.81 0.00