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:MED
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) 16 16.00 141.28 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.00 140.40 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 16.00 348.64 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.00 84.84 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 12 12.00 381.72 31.81
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 83.25 55.50
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 37.00 2775.00 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 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.00 291.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 13.00 630.50 48.50
Subtotal (Total Children Is Unduplicated) 57 123.50 5095.57 41.26
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 6.00 150.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 193 1384.50 69225.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 14 61.50 4174.62 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 36 244.00 16562.72 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 90.50 6143.14 67.88
Subtotal (Total Children Is Unduplicated) 232 1789.50 96418.44 53.88
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Total 1913.00 101514.01 53.07
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Number of Children (Unduplicated) With at Least One Service 257
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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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2067 1913.00 101514.01 398.50
Other 0 0.00 0.00 0.00
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Total 2067 1913.00 101514.01 398.50