CMS/EIP Fiscal Report Center: 51
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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 239.20 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.00 250.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 6.00 300.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 7 13.00 675.00 51.92
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 26.50 1950.00 73.58
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 11.00 825.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.50 150.00 60.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 83.50 600.00 7.19
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 42.00 2925.00 69.64
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 12.00 582.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 23 23.00 1115.50 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 1.00 225.00 225.00
Subtotal (Total Children Is Unduplicated) 101 238.50 10537.07 44.18
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 17 38.00 7567.90 199.16
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 2.00 137.72 68.86
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 18 17.25 862.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 7 8.50 425.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 6 2.75 68.75 25.00
CONPP-CONPP-CONSULT, PT, PHONE 6 3.75 93.75 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.00 31.25 31.25
CONSP-CONSP-CONSULT, SLP, PHONE 6 2.00 50.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 207.25 10362.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 63.50 3175.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 98 632.25 31612.50 50.00
INTR-INTR-INTERPRETER 2 5.00 85.00 17.00
OCCT-97530-OT SESSION BY LICENSED OT 37 162.25 10978.89 67.67
PHY-97110-PT SESSION BY LICENSED PT 34 153.50 10139.07 66.05
PHY-97110HM-PT SESSION BY PT ASST 1 12.50 638.26 51.06
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 126 835.00 54337.59 65.07
TRAN-TRAN-FAMILY TRANSPORTATION 1 672.00 136.29 0.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 488 106758 52118.50 0.49
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 1.50 75.00 50.00
Subtotal (Total Children Is Unduplicated) 522 109582 183407.15 1.67
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Total 109820.50 193944.22 1.77
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Number of Children (Unduplicated) With at Least One Service 527
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Center 51
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 2472 109666.00 193013.30 193013.30
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
15 154.50 930.92 0.00
Other 0 0.00 0.00 0.00
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Total 2487 109820.50 193944.22 193013.30