CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
Payclass Filters:TPIN
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 61.00 61.00
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 42.00 42.00
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 50.00 50.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 8 11.00 594.00 54.00
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 34.00 1700.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 15 48.00 3258.24 67.88
PHY-97110-PT SESSION BY LICENSED PT 7 15.00 1018.20 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 86.50 5871.62 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 337.00 168.50 0.50
Subtotal (Total Children Is Unduplicated) 43 520.50 12016.56 23.09
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Total 531.50 12610.56 23.73
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Number of Children (Unduplicated) With at Least One Service 46
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Center 07
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 22 382.00 2578.78 2578.78
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
73 149.50 10031.78 0.00
Other 0 0.00 0.00 0.00
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Total 95 531.50 12610.56 2578.78