CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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-92552-PURE TONE AUDIOMETRY -AIR ONLY 15 15.00 159.30 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 48.90 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 17 18.00 157.88 8.77
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 19 20.00 199.60 9.98
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 19 20.00 420.93 21.05
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 6.84 6.84
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 15 15.00 421.85 28.12
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 45.00 45.00
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 230.00 115.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.00 145.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 39 114.00 2571.74 22.56
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 40.00 1351.27 33.78
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 129 147.00 7350.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 0.50 12.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 1.75 87.50 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 23 21.25 1062.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.50 75.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 31 25.50 1275.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 7 4.25 106.25 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 80.00 2000.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 8.00 400.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 158 1709.75 85487.50 50.00
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 109 502.75 32653.16 64.95
OCCT-97530HM-OT SESSION BY OT ASST 13 35.50 1848.56 52.07
PHY-97110-PT SESSION BY LICENSED PT 121 476.00 30808.08 64.72
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 2 4.00 73.44 18.36
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 286 1354.75 90581.31 66.86
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 29 66.00 3585.12 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 545 123540 61770.00 0.50
Subtotal (Total Children Is Unduplicated) 736 128023 321633.44 2.51
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Total 128136.75 324205.18 2.53
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Number of Children (Unduplicated) With at Least One Service 742
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Center 10
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 4211 128136.75 324205.18 324205.18
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 4211 128136.75 324205.18 324205.18