CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2008 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
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.50 18.50 37.00
Subtotal (Total Children Is Unduplicated) 1 0.50 18.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.00 93.60 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 239.20 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 20.00 1500.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 15 18.00 1350.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 36.50 2731.20 74.83
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 20.00 1500.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.00 145.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 10 11.00 533.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 16.00 776.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 29.00 1323.17 45.63
Subtotal (Total Children Is Unduplicated) 81 167.50 10730.17 64.06
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 11.25 562.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 1 1.75 43.75 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 5.50 275.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 6.00 280.00 46.67
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.00 100.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 13.00 650.00 50.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 9 42.00 3083.64 73.42
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 304 5274.75 254097.50 48.17
INTR-INTR-INTERPRETER 4 51.00 2550.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 336 4342.00 285471.16 65.75
OCCT-97530HM-OT SESSION BY OT ASST 9 30.50 1656.76 54.32
PHY-97110-PT SESSION BY LICENSED PT 272 3301.25 211476.51 64.06
PHY-97110HM-PT SESSION BY PT ASST 5 62.25 3364.62 54.05
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 2 4.00 2000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 4 8.00 149.76 18.72
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SIC-SIC-SPECIAL INSTRUCTION CONSULTATION 2 8.00 400.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 763 10679.8 714874.63 66.94
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 801 287730 143555.00 0.50
Subtotal (Total Children Is Unduplicated) 1227 311577 1625165.07 5.22
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Total 311745.00 1635913.74 5.25
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Number of Children (Unduplicated) With at Least One Service 1239
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Center 09
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 13569 308355.75 1591002.71 1591108.52
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
355 3389.25 44911.03 1643.63
Other 0 0.00 0.00 0.00
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Total 13924 311745.00 1635913.74 1592752.15