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: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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 8.00 70.64 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 7.00 75.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 8.00 174.32 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.00 190.86 31.81
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 22 49.00 1461.18 29.82
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 19 93.00 6312.84 67.88
PHY-97110-PT SESSION BY LICENSED PT 25 187.75 12744.47 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 131.75 8943.19 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.50 59.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 60.00 30.00 0.50
Subtotal (Total Children Is Unduplicated) 60 477.00 28089.90 58.89
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Total 526.00 29551.08 56.18
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Number of Children (Unduplicated) With at Least One Service 67
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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
675 526.00 29551.08 0.00
Other 0 0.00 0.00 0.00
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Total 675 526.00 29551.08 0.00