CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 1 2.00 239.20 119.60
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.50 637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 8.00 570.75 71.34
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 90.00 90.00
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 105.71 52.86
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 1.50 123.50 82.33
Subtotal (Total Children Is Unduplicated) 21 30.50 2188.41 71.75
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 8.00 4149.69 518.71
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 100.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.00 50.00 50.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.00 150.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 22.00 1150.00 52.27
OCCT-97530-OT SESSION BY LICENSED OT 24 52.00 4733.51 91.03
PHY-97110-PT SESSION BY LICENSED PT 34 61.00 5455.87 89.44
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 50.25 100.50
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 3 6.00 112.32 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 317.00 26747.72 84.38
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 4 251.00 125.50 0.50
Subtotal (Total Children Is Unduplicated) 159 725.50 43824.86 60.41
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Total 756.00 46013.27 60.86
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Number of Children (Unduplicated) With at Least One Service 171
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Center 01
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 0 0.00 0.00 0.00
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
355 285.75 27298.58 11.88
Other 215 470.25 18714.69 0.00
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Total 570 756.00 46013.27 11.88