CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 3 3.00 145.50 48.50
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 3.00 65.37 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 4.00 127.24 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 6 6.00 625.00 104.17
EXIT-EXIT-TRANSITION ASSESSMENT 4 8.00 400.00 50.00
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
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 16.00 776.00 48.50
Subtotal (Total Children Is Unduplicated) 32 48.00 2376.28 49.51
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 1337.50 1337.50
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 11.25 562.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.00 25.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 3 5.00 250.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 18.75 937.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 13.00 650.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 29 182.00 9100.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 7.00 350.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 77 457.00 22850.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 8 23.50 1595.18 67.88
PHY-97110-PT SESSION BY LICENSED PT 11 74.50 5057.06 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 204.50 13881.46 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 360 69056.0 34528.00 0.50
Subtotal (Total Children Is Unduplicated) 374 70055.8 91155.45 1.30
----------------------------------------------------------------------------------------------------------------
Total 70103.75 93531.73 1.33
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 377
----------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
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 651 21409.75 28566.52 28566.52
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 679 21819.75 30446.49 30446.49
T 0 0.00 0.00 0.00
736 26874.25 34518.72 13.20
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2066 70103.75 93531.73 59026.21