CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 12 12.00 582.00 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 43.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 108.95 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 4 4.00 400.00 100.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 10 10.00 485.00 48.50
Subtotal (Total Children Is Unduplicated) 37 47.00 2065.45 43.95
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 8.00 673.60 84.20
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.25 112.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 22.00 1100.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 4.50 225.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 13.00 650.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 1.50 37.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 18.00 900.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 2.00 50.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 21 123.00 6150.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 82 485.00 24250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 15 104.75 7109.50 67.87
PHY-97110-PT SESSION BY LICENSED PT 11 50.25 3410.97 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 291.27 19773.19 67.89
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 367 60509.0 30254.50 0.50
Subtotal (Total Children Is Unduplicated) 383 61634.5 94696.76 1.54
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Total 61681.52 96762.21 1.57
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Number of Children (Unduplicated) With at Least One Service 386
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Center 53
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 624 17925.10 27789.27 27816.51
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 666 21787.50 29275.06 29275.06
939 21968.92 39697.88 0.00
Other 0 0.00 0.00 0.00
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Total 2229 61681.52 96762.21 57091.57