CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.00 95.43 31.81
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.00 119.60 119.60
EVAL-EVAL-DEVELOPMENTAL EVALUATION 10 13.00 710.75 54.67
EXIT-EXIT-TRANSITION ASSESSMENT 25 45.00 2250.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 3.50 194.25 55.50
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.37 257.76 58.98
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.50 305.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 73 84.50 4689.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 78 98.71 6154.46 62.35
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 12.09 906.66 74.99
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 13.08 844.50 64.56
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 159 248.00 13764.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 41.50 3112.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.00 242.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 10 11.00 501.06 45.55
Subtotal (Total Children Is Unduplicated) 334 614.75 35282.58 57.39
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 25.00 3575.87 143.03
AUD-HA_FUP-AUDIOLOGY SERVICES 2 2.00 100.00 50.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 217 218.25 10912.50 50.00
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 5 2.00 50.00 25.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 433 683.25 34162.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 28 9.25 231.25 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 152 96.25 4812.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 11 4.50 112.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 177 145.25 7262.50 50.00
CONPP-CONPP-CONSULT, PT, PHONE 2 0.50 12.50 25.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 264 199.75 9987.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 7 2.50 62.50 25.00
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 7.00 175.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 118 1059.93 31212.64 29.45
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 414 4859.45 242899.37 49.98
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 1 5.00 250.00 50.00
INTR-INTR-INTERPRETER 10 132.50 6625.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 68 604.61 27609.13 45.66
OCCT-97530HM-OT SESSION BY OT ASST 1 3.00 162.96 54.32
PHY-97110-PT SESSION BY LICENSED PT 60 500.62 27408.00 54.75
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 2.00 1000.00 500.00
SENS-V5264-EARMOLD 2 4.00 74.88 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 155 1467.94 92763.17 63.19
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 14 54.00 2933.28 54.32
TRAN-TRAN-FAMILY TRANSPORTATION 1 98.00 1875.23 19.14
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 674 317966 158983.00 0.50
Subtotal (Total Children Is Unduplicated) 766 328154 665278.78 2.03
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Total 328768.30 700561.36 2.13
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Number of Children (Unduplicated) With at Least One Service 797
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Center 05
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 15038 326541.03 694867.98 695239.35
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
118 2227.27 5693.38 0.00
Other 0 0.00 0.00 0.00
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Total 15156 328768.30 700561.36 695239.35