CMS/EIP Fiscal Report Center: 54
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 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.00 43.20 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
EXIT-EXIT-TRANSITION ASSESSMENT 19 48.75 2437.50 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 19.50 1462.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 14.00 777.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 25.50 1912.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 16.00 1200.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 36.00 1998.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 14.00 1050.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.00 533.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 3.19 154.34 48.38
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 2.00 30.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 19.00 921.50 48.50
Subtotal (Total Children Is Unduplicated) 107 235.94 13746.14 58.26
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 4.50 225.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 40 41.50 2075.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 3 2.25 56.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 11.75 587.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 9.75 487.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 42 40.50 2025.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 3 3.00 75.00 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 2 191.20 2390.00 12.50
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 31.25 1562.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 89 882.25 44112.50 50.00
INTR-INTR-INTERPRETER 33 199.00 9980.00 50.15
OCCT-97530-OT SESSION BY LICENSED OT 85 425.04 28702.49 67.53
OCCT-97530HM-OT SESSION BY OT ASST 20 108.55 5896.30 54.32
PHY-97110-PT SESSION BY LICENSED PT 43 228.13 14910.41 65.36
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 1.00 114.00 114.00
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 98 610.12 40748.50 66.79
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 102.25 5554.22 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 567 151241 105563.20 0.70
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 3 18.00 900.00 50.00
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 3 5.00 250.00 50.00
Subtotal (Total Children Is Unduplicated) 632 154157 266240.34 1.73
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Total 154393.23 279986.48 1.81
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Number of Children (Unduplicated) With at Least One Service 637
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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 2872 154224.23 279820.38 279820.38
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
3 169.00 166.10 0.00
Other 0 0.00 0.00 0.00
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Total 2875 154393.23 279986.48 279820.38