CMS/EIP Fiscal Report Center: 02
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Agency Filter:EXT
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 2.00 230.00 115.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 4.00 200.00 50.00
EXIT-EXIT-TRANSITION ASSESSMENT 34 62.00 3100.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.00 600.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 47 87.00 6525.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 45.00 3375.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.00 750.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 97.00 5383.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 21.00 1575.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 21.77 21.77
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 123 354.00 22732.77 64.22
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 727.00 727.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 14 16.50 825.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 23 18.50 925.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 4 3.00 75.00 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 16.00 800.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 10.50 525.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.50 12.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 70 441.50 22075.00 50.00
INTR-INTR-INTERPRETER 3 25.00 1205.00 48.20
OCCT-97530-OT SESSION BY LICENSED OT 29 140.25 9347.07 66.65
PHY-97110-PT SESSION BY LICENSED PT 15 71.50 3651.69 51.07
PHY-97110HM-PT SESSION BY PT ASST 1 0.75 31.25 41.67
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 1 2.00 36.00 18.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 372.00 24781.98 66.62
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 335 84606.0 42303.00 0.50
Subtotal (Total Children Is Unduplicated) 342 85727.0 108320.49 1.26
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Total 86081.00 131053.26 1.52
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Number of Children (Unduplicated) With at Least One Service 357
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Center 02
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 1139 49979.25 65432.83 65432.81
952 36101.75 65620.43 0.00
Other 0 0.00 0.00 0.00
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Total 2091 86081.00 131053.26 65432.81