CMS/EIP Fiscal Report Center: 55
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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-V5090-DISPENSING FEE PER HEARING AID 1 2.00 212.00 106.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.50 83.25 55.50
EXIT-EXIT-TRANSITION ASSESSMENT 6 8.00 470.75 58.84
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 61 92.90 6967.30 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 21.77 1632.74 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 17.00 1275.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 48.50 2691.75 55.50
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 3.79 184.00 48.55
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.00 339.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 18.59 901.50 48.49
Subtotal (Total Children Is Unduplicated) 119 222.05 14806.29 66.68
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 6.00 1372.85 228.81
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.00 200.00 50.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.25 12.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.00 50.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 19.00 950.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 26 181.50 9075.00 50.00
INTR-INTR-INTERPRETER 2 18.00 792.00 44.00
OCCT-97530-OT SESSION BY LICENSED OT 55 225.87 15327.12 67.86
PHY-97110-PT SESSION BY LICENSED PT 40 187.68 12741.50 67.89
PHY-97110HM-PT SESSION BY PT ASST 4 12.00 651.84 54.32
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 1 2.00 474.24 237.12
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 131 894.90 52678.29 58.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 329 79541.0 59712.50 0.75
Subtotal (Total Children Is Unduplicated) 364 81096.2 154125.28 1.90
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Total 81318.25 168931.57 2.08
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Number of Children (Unduplicated) With at Least One Service 415
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Center 55
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 3024 46156.91 93168.06 93168.06
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
2505 35161.34 75763.51 0.00
Other 0 0.00 0.00 0.00
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Total 5529 81318.25 168931.57 93168.06