CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 3 3.00 0.00 0.00
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 5.00 575.00 115.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 33.50 2512.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 36.50 2025.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.00 900.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.00 322.90 46.13
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 9 9.00 391.50 43.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.00 146.95 36.74
SPCH-92506-SPEECH EVAL BY LICENSED SLP 31 32.00 1453.36 45.42
Subtotal (Total Children Is Unduplicated) 73 160.00 9837.46 61.48
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 3095.00 1547.50
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 106 188.00 6475.00 34.44
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 5 4.00 100.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 60 200.75 5112.50 25.47
CONIP-CONIP-CONSULT, ITDS, PHONE 4 3.50 87.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 30.50 1525.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 23.25 1100.00 47.31
CONPP-CONPP-CONSULT, PT, PHONE 1 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 56 108.00 5400.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 3 4.00 100.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 152 1200.50 60025.00 50.00
INTR-INTR-INTERPRETER 7 58.00 3480.00 60.00
OCCT-97530-OT SESSION BY LICENSED OT 76 452.00 27744.14 61.38
PHY-97110-PT SESSION BY LICENSED PT 52 293.50 19224.91 65.50
SENS-V5014-HEARING AID REPAIR BY MANUFACTURER 1 2.00 228.00 114.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 456.00 228.00
SENS-V5264-EARMOLD 2 4.00 72.00 18.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 144 740.75 47721.60 64.42
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 359 69707.0 34848.00 0.50
Subtotal (Total Children Is Unduplicated) 487 73024.8 216819.65 2.97
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Total 73187.75 226657.11 3.10
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Number of Children (Unduplicated) With at Least One Service 504
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Center 03
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 3829 49879.75 160431.46 160431.46
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
1645 23308.00 66225.65 0.00
Other 0 0.00 0.00 0.00
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Total 5474 73187.75 226657.11 160431.46