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: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) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 10.00 485.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 17.00 824.50 48.50
Subtotal (Total Children Is Unduplicated) 23 41.00 1844.36 44.98
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 21 95.25 6466.50 67.89
OCCT-97530HM-OT SESSION BY OT ASST 1 0.50 27.16 54.32
PHY-97110-PT SESSION BY LICENSED PT 14 84.25 5718.89 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 129.42 8783.47 67.87
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.00 39.60 13.20
Subtotal (Total Children Is Unduplicated) 38 313.42 21089.94 67.29
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Total 354.42 22934.30 64.71
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Number of Children (Unduplicated) With at Least One Service 50
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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 2 0.88 60.00 60.00
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
584 353.54 22874.30 0.00
Other 0 0.00 0.00 0.00
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Total 586 354.42 22934.30 60.00