CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 21.50 1612.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 11.00 533.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 436.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 30 54.50 3122.92 57.30
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 5.00 125.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 224 1536.00 76800.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 17 79.50 5396.46 67.88
PHY-97110-PT SESSION BY LICENSED PT 21 126.75 8603.79 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 108.00 7331.04 67.88
Subtotal (Total Children Is Unduplicated) 241 1855.25 98256.29 52.96
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Total 1909.75 101379.21 53.09
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Number of Children (Unduplicated) With at Least One Service 250
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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 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
2034 1909.75 101379.21 800.00
Other 0 0.00 0.00 0.00
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Total 2034 1909.75 101379.21 800.00