CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 17 17.00 180.54 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 3 3.00 47.14 15.71
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 19 20.00 175.70 8.79
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 19 20.00 207.60 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 19 20.00 431.01 21.55
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 12 13.00 367.64 28.28
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
Subtotal (Total Children Is Unduplicated) 19 97.00 1888.03 19.46
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 24.00 2493.86 103.91
AUD-HA_FUP-AUDIOLOGY SERVICES 4 4.00 174.69 43.67
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 144 176.75 8837.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 1.75 43.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 28 28.75 1437.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 11 3.00 75.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 45 34.00 1700.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 5 1.50 37.50 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 20 129.75 3243.75 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 141 1764.25 84532.50 47.91
INTR-INTR-INTERPRETER 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 126 484.00 31258.19 64.58
OCCT-97530HM-OT SESSION BY OT ASST 18 48.50 2483.00 51.20
PHY-97110-PT SESSION BY LICENSED PT 153 552.75 35568.90 64.35
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 6.00 112.32 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 288 1238.00 83418.31 67.38
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 16 63.50 3449.32 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 419 91660.0 45830.00 0.50
Subtotal (Total Children Is Unduplicated) 654 96226.5 306270.33 3.18
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Total 96323.50 308158.36 3.20
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Number of Children (Unduplicated) With at Least One Service 658
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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 0 0.00 0.00 0.00
P 3912 96033.50 305991.96 305991.96
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
14 290.00 2166.40 0.00
Other 0 0.00 0.00 0.00
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Total 3926 96323.50 308158.36 305991.96