CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 115.00 115.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.50 125.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 4 6.00 300.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 66.00 4912.50 74.43
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 17.00 1275.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 48.50 2691.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 67 158.50 10625.75 67.04
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 11.00 1421.70 129.25
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 5.00 242.50 48.50
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 4.50 225.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 11 6.00 300.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.50 25.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 13.00 650.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 1.50 37.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 45 272.50 13625.00 50.00
INTR-INTR-INTERPRETER 3 9.50 475.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 22 133.00 9002.69 67.69
PHY-97110-PT SESSION BY LICENSED PT 8 26.25 1699.18 64.73
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 1.00 399.00 399.00
SENS-V5264-EARMOLD 2 6.00 90.72 15.12
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 64 449.25 30227.59 67.28
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 218 59554.0 29672.00 0.50
Subtotal (Total Children Is Unduplicated) 246 60493.0 88092.88 1.46
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Total 60651.50 98718.63 1.63
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Number of Children (Unduplicated) With at Least One Service 260
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Center 02
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 1061 41173.00 65898.37 65898.37
512 19471.50 32667.26 678.88
Other 2 7.00 153.00 0.00
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Total 1575 60651.50 98718.63 66577.25