CMS/EIP Fiscal Report Center: 53
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
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.00 48.50 48.50
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 3.00 32.40 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.00 16.88 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 3.00 65.37 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.00 63.62 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 6 6.00 650.00 108.33
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.00 15.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.00 388.00 48.50
Subtotal (Total Children Is Unduplicated) 21 32.00 1453.55 45.42
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 55.00 55.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 34 43.00 2150.00 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 3.00 75.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 7 6.50 325.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 10.00 500.00 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 1.50 37.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 6.00 300.00 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 8.00 200.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 30 188.00 9400.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 10.00 500.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 67 500.00 25000.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 10 35.00 2375.80 67.88
PHY-97110-PT SESSION BY LICENSED PT 17 98.32 6675.09 67.89
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 176.00 11946.88 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 312 60100.0 30050.00 0.50
Subtotal (Total Children Is Unduplicated) 332 61186.6 89596.52 1.46
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Total 61218.57 91050.07 1.49
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Number of Children (Unduplicated) With at Least One Service 332
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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 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 636 18474.40 27175.99 27157.24
T 642 19767.00 28341.23 28341.23
791 22977.17 35532.85 0.00
Other 0 0.00 0.00 0.00
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Total 2069 61218.57 91050.07 55498.47