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:TPIN
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 2 4.00 478.40 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 7.00 525.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.00 375.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 13.00 975.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 12.00 900.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.00 194.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 7 7.00 339.50 48.50
Subtotal (Total Children Is Unduplicated) 31 55.00 3932.40 71.50
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 102 431.50 29256.28 67.80
OCCT-97530HM-OT SESSION BY OT ASST 5 14.00 760.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 114 460.50 31251.96 67.87
PHY-97110HM-PT SESSION BY PT ASST 3 29.00 1575.28 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 2 6.00 112.32 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 194 950.75 64435.09 67.77
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 1.00 0.50 0.50
Subtotal (Total Children Is Unduplicated) 268 1897.25 128872.75 67.93
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Total 1952.25 132805.15 68.03
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Number of Children (Unduplicated) With at Least One Service 282
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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 26 36.50 2458.24 5238.83
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
1045 1915.75 130346.91 1938.00
Other 0 0.00 0.00 0.00
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Total 1071 1952.25 132805.15 7176.83