CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 17.4400 8.7200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.7100 21.8550
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 31.5200 31.5200
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.000000 125.0000 125.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 27.500000 2062.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 50.000000 3750.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 13.000000 630.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.000000 582.0000 48.5000
Subtotal (Total Children Is Unduplicated) 65 124.500000 8088.6700 64.9692
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 9.000000 660.7800 73.4200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 34.000000 850.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 222 1609.250000 80462.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 71.000000 4819.4800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 30 199.000000 13508.1200 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 199.000000 13508.1200 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
Subtotal (Total Children Is Unduplicated) 260 2122.250000 113822.2000 53.6328
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Total 2246.750000 121910.8700 54.2610
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Number of Children (Unduplicated) With at Least One Service 285
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2349 2246.750000 121910.8700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2349 2246.750000 121910.8700 0.0000