CMS/EIP Fiscal Report Center: 07
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 212.00 106.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 9 9.00 436.50 48.50
Subtotal (Total Children Is Unduplicated) 22 34.00 1712.15 50.36
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 15.00 750.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 17 53.00 3543.56 66.86
PHY-97110-PT SESSION BY LICENSED PT 12 38.25 2596.41 67.88
SENS-FM-FM RECEIVER HEARING AID 2 2.00 2989.75 1494.88
SENS-V5264-EARMOLD 3 6.00 107.32 17.89
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 113.75 7721.35 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 86.00 43.00 0.50
Subtotal (Total Children Is Unduplicated) 59 315.00 17801.39 56.51
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Total 349.00 19513.54 55.91
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Number of Children (Unduplicated) With at Least One Service 68
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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 20 133.25 2968.61 2968.61
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
119 215.75 16544.93 0.00
Other 0 0.00 0.00 0.00
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Total 139 349.00 19513.54 2968.61