CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 0.54 0.54
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 6.01 6.01
EXIT-EXIT-TRANSITION ASSESSMENT 7 9.00 450.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 11.50 862.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.50 838.50 67.08
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 23 44.00 2700.05 61.36
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 6.00 651.08 108.51
AUD-HA_FUP-AUDIOLOGY SERVICES 1 2.00 82.00 41.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 52 66.50 3325.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 1.50 37.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 3.50 175.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 32 23.75 1187.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 27.00 1350.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 16 30.50 1525.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 177 1558.75 77877.50 49.96
INTR-INTR-INTERPRETER 2 9.00 450.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 179 1316.00 87743.32 66.67
OCCT-97530HM-OT SESSION BY OT ASST 3 10.75 396.04 36.84
PHY-97110-PT SESSION BY LICENSED PT 136 794.25 52318.68 65.87
PHY-97110HM-PT SESSION BY PT ASST 3 10.00 538.81 53.88
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 2 4.00 260.00 65.00
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 463 3451.00 232712.58 67.43
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 696 203173 101586.50 0.50
Subtotal (Total Children Is Unduplicated) 930 210490 562253.95 2.67
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Total 210533.50 564954.00 2.68
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Number of Children (Unduplicated) With at Least One Service 935
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Center 09
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 3165 132343.00 348587.35 348597.07
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 1626 69936.00 191689.58 191689.58
431 8254.50 24677.07 298.38
Other 0 0.00 0.00 0.00
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Total 5222 210533.50 564954.00 540585.03