CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 2 4.00 90.00 22.50
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 54.38 27.19
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 6.00 225.85 37.64
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 2.00 100.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 6 8.00 400.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 30.50 2287.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 12.00 900.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.00 830.95 69.25
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 24.50 1359.75 55.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 41 104.00 6356.23 61.12
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.25 212.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 10 8.00 400.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.25 6.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 3.25 162.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 6.75 337.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.50 12.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 56 332.00 16600.00 50.00
INTR-INTR-INTERPRETER 2 8.50 360.00 42.35
OCCT-97530-OT SESSION BY LICENSED OT 23 136.75 8878.64 64.93
PHY-97110-PT SESSION BY LICENSED PT 11 34.25 1881.60 54.94
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 58 438.25 29598.41 67.54
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 213 58831.0 29389.36 0.50
Subtotal (Total Children Is Unduplicated) 234 59803.8 87839.26 1.47
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Total 59907.75 94195.49 1.57
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Number of Children (Unduplicated) With at Least One Service 246
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Center 02
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 0 0.00 0.00 0.00
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 708 23794.50 35296.83 35296.83
1042 36113.25 58898.66 0.00
Other 0 0.00 0.00 0.00
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Total 1750 59907.75 94195.49 35296.83