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: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-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.00 61.81 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 5.00 54.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.00 174.32 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 7.00 222.67 31.81
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 36.00 2700.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 18.00 1350.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 14 14.00 679.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 14.00 679.00 48.50
Subtotal (Total Children Is Unduplicated) 67 125.00 6777.26 54.22
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 214 1437.50 71875.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 23 84.50 5735.86 67.88
PHY-97110-PT SESSION BY LICENSED PT 38 206.75 14034.19 67.88
PHY-97110HM-PT SESSION BY PT ASST 10 31.50 1711.08 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 148.00 10046.24 67.88
Subtotal (Total Children Is Unduplicated) 259 1908.25 103402.37 54.19
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Total 2033.25 110179.63 54.19
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Number of Children (Unduplicated) With at Least One Service 283
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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 1 2.00 150.00 150.00
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
2190 2031.25 110029.63 200.00
Other 0 0.00 0.00 0.00
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Total 2191 2033.25 110179.63 350.00