CMS/EIP Fiscal Report Center: 03
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
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 6 6.00 0.00 0.00
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 115.00 57.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 41.00 3075.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 17.00 1275.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 36.50 2025.75 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 16.00 663.73 41.48
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 72.00 36.00
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.00 395.00 43.89
SPCH-92506-SPEECH EVAL BY LICENSED SLP 30 30.00 1299.38 43.31
Subtotal (Total Children Is Unduplicated) 85 154.50 8969.36 58.05
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.00 365.08 121.69
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 87 103.50 5125.00 49.52
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 3 2.50 62.50 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 55 71.25 3562.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 16 15.00 375.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 31.50 1575.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 1.75 43.75 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 22.75 1137.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 1 0.25 6.25 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 84.25 3500.00 41.54
CONSP-CONSP-CONSULT, SLP, PHONE 9 12.00 300.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 170 1282.00 64100.00 50.00
INTR-INTR-INTERPRETER 6 32.75 1637.00 49.98
OCCT-97530-OT SESSION BY LICENSED OT 71 415.75 25177.16 60.56
PHY-97110-PT SESSION BY LICENSED PT 52 277.75 17717.10 63.79
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 4.00 906.00 226.50
SENS-V5264-EARMOLD 2 4.00 72.00 18.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 124 679.25 43896.75 64.63
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 371 67680.0 33814.00 0.50
Subtotal (Total Children Is Unduplicated) 504 70723.3 203372.59 2.88
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Total 70883.75 212341.95 3.00
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Number of Children (Unduplicated) With at Least One Service 530
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Center 03
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 5456 70877.75 212341.95 212341.95
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
6 6.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 5462 70883.75 212341.95 212341.95