CMS/EIP Fiscal Report Center: 54
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.50 18.50 37.00
Subtotal (Total Children Is Unduplicated) 1 0.50 18.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 21.00 185.43 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 40 42.00 453.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 10 10.00 84.40 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 33 34.00 740.86 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 10 10.00 282.80 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 12 12.00 381.72 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 15.50 1162.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 5.00 375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 5.50 305.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 65.50 5100.00 77.86
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 40 42.00 3150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 37.50 2081.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 22.00 1650.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 5 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 16 22.00 1067.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.00 242.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 10 10.00 485.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 46 44.00 2134.00 48.50
Subtotal (Total Children Is Unduplicated) 230 428.00 21438.87 50.09
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.00 50.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 3.75 187.50 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 35 31.00 1550.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 16.50 825.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 7.25 362.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 52 44.25 2212.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.50 37.50 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 7 127.00 6350.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 224 1775.25 88762.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 1.00 50.00 50.00
INTR-INTR-INTERPRETER 16 78.00 3900.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 189 1200.32 81477.55 67.88
OCCT-97530HM-OT SESSION BY OT ASST 13 63.50 3449.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 105 455.10 30801.10 67.68
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 256 1260.35 85545.80 67.87
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 438 125851 107020.05 0.85
Subtotal (Total Children Is Unduplicated) 622 130918 412648.14 3.15
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Total 131346.77 434105.51 3.31
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Number of Children (Unduplicated) With at Least One Service 672
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Center 54
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 2488 128577.27 283873.39 283771.52
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
1085 2769.50 150232.12 0.00
Other 0 0.00 0.00 0.00
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Total 3573 131346.77 434105.51 283771.52