CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Agency Filter:EXT
Payclass Filters:TPIN
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 18.72 18.72
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 25.04 25.04
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.00 300.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 0.00 29.78 0.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 49.04 49.04
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 173.87 86.94
Subtotal (Total Children Is Unduplicated) 10 12.00 743.45 61.95
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 7.00 5605.61 800.80
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.25 12.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 36 107.00 5423.90 50.69
OCCT-97530-OT SESSION BY LICENSED OT 29 106.75 9120.01 85.43
PHY-97110-PT SESSION BY LICENSED PT 63 342.00 27118.14 79.29
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 115 538.25 40895.44 75.98
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 28.00 14.00 0.50
Subtotal (Total Children Is Unduplicated) 195 1131.25 88252.80 78.01
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Total 1143.25 88996.25 77.84
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Number of Children (Unduplicated) With at Least One Service 200
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Center 01
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 5 5.00 339.40 0.00
D 1 1.00 67.88 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
660 465.50 45062.93 237.58
Other 740 671.75 43526.04 0.00
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Total 1406 1143.25 88996.25 237.58