CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
Payclass Filters:MED
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-92552-PURE TONE AUDIOMETRY -AIR ONLY 8 8.00 84.96 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.00 61.81 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.00 64.38 10.73
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 108.95 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 141.40 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
Subtotal (Total Children Is Unduplicated) 9 32.00 581.10 18.16
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 118.00 2950.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 136 1901.00 95050.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 171 1224.25 83034.29 67.82
OCCT-97530HM-OT SESSION BY OT ASST 24 89.25 4848.06 54.32
PHY-97110-PT SESSION BY LICENSED PT 295 2333.75 158387.83 67.87
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 291 2216.50 150182.62 67.76
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 13 56.75 3082.66 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 3 2.75 36.30 13.20
Subtotal (Total Children Is Unduplicated) 568 7944.25 497609.20 62.64
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Total 7976.25 498190.30 62.46
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Number of Children (Unduplicated) With at Least One Service 573
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Center 10
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 1 1.50 101.82 0.00
P 1 1.00 25.00 50.00
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 0 0.00 0.00 0.00
4185 7973.75 498063.48 0.00
Other 0 0.00 0.00 0.00
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Total 4187 7976.25 498190.30 50.00