CMS/EIP Fiscal Report Center: 51
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 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-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.00 250.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 3.00 150.00 50.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.50 225.00 64.29
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.50 262.50 75.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 14 21.50 1083.00 50.37
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 43.50 3037.50 69.83
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 23.00 1687.50 73.37
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 8.50 637.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 17.50 874.50 49.97
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 70.50 4987.50 70.74
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 22.00 1067.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 8 8.00 361.79 45.22
PSTH-97001-EVAL BY LICENSED PT, INITIAL 21 21.00 1018.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 21 22.00 1067.00 48.50
VISF-VISF-VISION EVALUATION FUNCTIONAL 1 3.00 245.00 81.67
Subtotal (Total Children Is Unduplicated) 162 288.00 17861.70 62.02
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 14 84.00 4366.08 51.98
AUD-92630-AUD REHAB PRELING HEARING LOSS 2 9.00 529.09 58.79
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 28 28.50 1375.00 48.25
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 11 10.75 512.50 47.67
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 1.25 62.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 1.75 81.25 46.43
CONPP-CONPP-CONSULT, PT, PHONE 4 1.00 25.00 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 27.00 106.25 3.94
CONSP-CONSP-CONSULT, SLP, PHONE 3 0.75 18.75 25.00
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 13.00 954.46 73.42
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 179.25 8962.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 194 1239.00 61629.00 49.74
OCCT-97530-OT SESSION BY LICENSED OT 107 615.00 40318.90 65.56
OCCT-97530HM-OT SESSION BY OT ASST 21 126.75 4826.22 38.08
PHY-97110-PT SESSION BY LICENSED PT 116 665.00 40015.43 60.17
PHY-97110HM-PT SESSION BY PT ASST 20 101.50 5480.50 54.00
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.00 86.00 43.00
SENS-V5050-MED HEARING AID - ANALOG/DIGITAL 2 4.00 948.48 237.12
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 163 1042.00 70077.82 67.25
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.50 244.44 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 6 12.75 168.30 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 382 102796 49784.50 0.48
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 12.00 840.00 70.00
Subtotal (Total Children Is Unduplicated) 432 106979 291456.66 2.72
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Total 107267.00 309318.36 2.88
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Number of Children (Unduplicated) With at Least One Service 441
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Center 51
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 1969 104871.50 165218.26 165150.30
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
981 2395.50 144100.10 0.00
Other 0 0.00 0.00 0.00
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Total 2950 107267.00 309318.36 165150.30