CMS/EIP Fiscal Report Center: 51
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-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.00 250.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 3.00 150.00 50.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.50 150.00 60.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 13 20.00 999.75 49.99
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 22.00 1425.00 64.77
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 10.50 750.00 71.43
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 10.00 458.25 45.83
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 30.50 2025.00 66.39
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.00 97.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 70.79 35.40
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 10 10.00 485.00 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 3.00 245.00 81.67
Subtotal (Total Children Is Unduplicated) 83 141.50 8529.40 60.28
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 70.00 3202.24 45.75
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 9.00 529.09 58.79
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 28 28.50 1375.00 48.25
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 11 10.75 512.50 47.67
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 1.25 62.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 1.75 81.25 46.43
CONPP-CONPP-CONSULT, PT, PHONE 4 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 27.00 106.25 3.94
CONSP-CONSP-CONSULT, SLP, PHONE 3 0.75 18.75 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 179.25 8962.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 81 500.25 24887.50 49.75
OCCT-97530-OT SESSION BY LICENSED OT 42 232.25 14337.83 61.73
OCCT-97530HM-OT SESSION BY OT ASST 3 47.25 467.10 9.89
PHY-97110-PT SESSION BY LICENSED PT 34 228.50 10568.91 46.25
PHY-97110HM-PT SESSION BY PT ASST 2 2.50 135.80 54.32
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.00 86.00 43.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 4.00 948.48 237.12
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 625.00 41771.86 66.83
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 382 102683 49728.00 0.48
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 12.00 840.00 70.00
Subtotal (Total Children Is Unduplicated) 416 104668 158690.25 1.52
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Total 104809.75 167219.65 1.60
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Number of Children (Unduplicated) With at Least One Service 422
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Center 51
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 1964 104741.50 164074.15 164074.07
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
27 68.25 3145.50 0.00
Other 0 0.00 0.00 0.00
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Total 1991 104809.75 167219.65 164074.07