CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Agency Filter:EXT
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-V5010-ASSESSMENT FOR HEARING AID 1 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 11.00 825.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 9.00 675.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 21.00 1575.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 18.00 1350.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.00 145.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 12 12.00 582.00 48.50
Subtotal (Total Children Is Unduplicated) 54 93.00 6381.50 68.62
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.50 125.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 28.00 2055.76 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 235 2005.75 96787.50 48.26
INTR-INTR-INTERPRETER 2 18.00 900.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 295 1827.25 122319.46 66.94
OCCT-97530HM-OT SESSION BY OT ASST 10 26.50 1439.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 293 1744.25 116300.32 66.68
PHY-97110HM-PT SESSION BY PT ASST 12 100.75 5472.74 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 4.00 2000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 3 8.00 149.76 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 602 4059.00 273432.25 67.36
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 457 103185 51592.50 0.50
Subtotal (Total Children Is Unduplicated) 850 113014 673155.61 5.96
----------------------------------------------------------------------------------------------------------------
Total 113106.50 679537.11 6.01
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 863
----------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 2096 68262.75 254822.03 257602.62
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 1227 39900.50 140082.80 140082.80
2005 4942.25 284557.28 3033.92
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 5329 113106.50 679537.11 400719.34