CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.00 61.81 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 11.00 118.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 10.00 217.90 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 0.71 20.26 28.54
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 5.00 136.07 27.21
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
EXIT-EXIT-TRANSITION ASSESSMENT 2 1.75 87.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.68 51.64 75.94
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 1.50 112.50 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.70 652.52 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.40 405.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 1.92 93.50 48.70
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 7.69 373.37 48.55
Subtotal (Total Children Is Unduplicated) 38 74.85 3177.37 42.45
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EI Services,Class #03
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.00 50.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 2.25 112.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.00 50.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 12 39.50 1987.50 50.32
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.50 175.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 34 103.95 7071.02 68.02
OCCT-97530HM-OT SESSION BY OT ASST 1 0.80 43.54 54.43
PHY-97110-PT SESSION BY LICENSED PT 15 50.27 3416.20 67.96
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 85.70 5824.06 67.96
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 5.00 271.60 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 12 1414.00 989.80 0.70
Subtotal (Total Children Is Unduplicated) 99 1709.72 20053.69 11.73
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Total 1784.57 23231.06 13.02
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Number of Children (Unduplicated) With at Least One Service 125
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Center 54
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
238 1784.57 23231.06 0.00
Other 0 0.00 0.00 0.00
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Total 238 1784.57 23231.06 0.00