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: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-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 36 45.00 3375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 33 42.00 3150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 43.00 3225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 46.00 3450.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 12.00 582.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 21.00 1018.50 48.50
Subtotal (Total Children Is Unduplicated) 106 233.00 16248.90 69.74
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 25.00 1250.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 209 1575.50 106968.36 67.89
OCCT-97530HM-OT SESSION BY OT ASST 9 51.50 2797.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 222 1761.75 119478.99 67.82
PHY-97110HM-PT SESSION BY PT ASST 4 67.00 3639.44 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 3 8.00 149.76 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 355 3230.25 219316.37 67.89
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.50 244.44 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 7.00 92.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 51.00 25.50 0.50
Subtotal (Total Children Is Unduplicated) 508 6785.50 455436.98 67.12
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Total 7018.50 471685.88 67.21
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Number of Children (Unduplicated) With at Least One Service 546
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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 56 82.00 5451.86 11295.30
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
3610 6936.50 466234.02 3036.00
Other 0 0.00 0.00 0.00
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Total 3666 7018.50 471685.88 14331.30