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:MED
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 2 2.00 21.24 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.38 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 28.28 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
Subtotal (Total Children Is Unduplicated) 3 8.00 218.95 27.37
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 32.00 800.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 74 539.00 26950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 90 277.00 18802.76 67.88
OCCT-97530HM-OT SESSION BY OT ASST 15 20.75 1127.14 54.32
PHY-97110-PT SESSION BY LICENSED PT 177 570.25 38708.57 67.88
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 167 544.00 36926.72 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 13.50 733.32 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 2 1.75 23.10 13.20
Subtotal (Total Children Is Unduplicated) 344 2000.25 124109.05 62.05
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Total 2008.25 124328.00 61.91
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Number of Children (Unduplicated) With at Least One Service 345
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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 1 1.00 25.00 50.00
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
1080 2007.25 124303.00 0.00
Other 0 0.00 0.00 0.00
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Total 1081 2008.25 124328.00 50.00