CMS/EIP Fiscal Report Center: 10
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-92552-PURE TONE AUDIOMETRY -AIR ONLY 17 18.00 189.77 10.54
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 17.34 8.67
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 23.00 161.92 7.04
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 24 27.00 242.08 8.97
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 23 25.00 452.04 18.08
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 17 18.25 418.70 22.94
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 2.00 124.20 62.10
Subtotal (Total Children Is Unduplicated) 30 116.25 1614.49 13.89
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 14 65.00 5641.14 86.79
AUD-HA_FUP-AUDIOLOGY SERVICES 5 7.00 338.77 48.40
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 119 145.50 7275.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 17.25 862.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.00 50.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 26 28.00 1400.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.00 50.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 16 101.75 2543.75 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 106 1162.75 54002.50 46.44
OCCT-97530-OT SESSION BY LICENSED OT 133 536.00 34949.85 65.20
OCCT-97530HM-OT SESSION BY OT ASST 21 51.25 2692.69 52.54
PHY-97110-PT SESSION BY LICENSED PT 161 622.75 40461.96 64.97
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 1.00 9.12 9.12
SENS-V5264-EARMOLD 2 3.00 48.44 16.15
SHIN-EIIF_NM-INITIAL SHINE SERVICES, IND NONMED 3 5.75 287.50 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 298 1333.25 89718.67 67.29
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 45.00 2434.89 54.11
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 405 82520.0 41250.00 0.50
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 14 63.75 3187.50 50.00
Subtotal (Total Children Is Unduplicated) 651 86715.0 288229.28 3.32
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Total 86831.25 289843.77 3.34
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Number of Children (Unduplicated) With at Least One Service 659
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Center 10
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 3729 86831.25 289843.77 289843.77
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
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 3729 86831.25 289843.77 289843.77