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
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-V5010-ASSESSMENT FOR HEARING AID 1 2.00 93.60 46.80
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.00 525.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.00 375.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.00 194.00 48.50
Subtotal (Total Children Is Unduplicated) 14 23.00 1430.10 62.18
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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 171 1534.75 73237.50 47.72
INTR-INTR-INTERPRETER 2 18.00 900.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 182 1014.00 67149.99 66.22
OCCT-97530HM-OT SESSION BY OT ASST 4 8.50 461.72 54.32
PHY-97110-PT SESSION BY LICENSED PT 141 704.00 45694.93 64.91
PHY-97110HM-PT SESSION BY PT ASST 1 6.00 325.92 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 383 2551.75 171221.94 67.10
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 457 103184 51592.00 0.50
Subtotal (Total Children Is Unduplicated) 666 109058 413902.20 3.80
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Total 109080.50 415332.30 3.81
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Number of Children (Unduplicated) With at Least One Service 669
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Center 09
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 2064 68205.25 251099.23 251099.23
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
191 974.75 24150.27 1095.92
Other 0 0.00 0.00 0.00
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Total 3482 109080.50 415332.30 392277.95