CMS/EIP Fiscal Report Center: 51
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
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.00 36.07 36.07
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.00 35.32 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.00 64.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.00 130.74 21.79
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.00 31.81 31.81
AUDE-92682-CONDITIONED PLAY AUDIOMETRY 1 1.00 21.34 21.34
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 478.40 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 12 12.00 1500.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 37 38.50 1925.00 50.00
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 3 3.50 180.50 51.57
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 7.00 450.00 64.29
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 6.00 375.00 62.50
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.50 75.00 50.00
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 42 55.50 3089.33 55.66
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 107 119.50 8025.00 67.15
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 63 68.50 4618.07 67.42
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 15.00 995.45 66.36
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 25.50 1133.25 44.44
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 97 106.50 7250.00 68.08
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 9 11.00 456.31 41.48
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 32 32.00 1552.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 10 11.00 442.23 40.20
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 22.00 1067.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 53 56.00 2698.65 48.19
VISF-VISF-VISION EVALUATION FUNCTIONAL 8 31.00 2205.00 71.13
Subtotal (Total Children Is Unduplicated) 350 654.00 39511.27 60.41
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 33 184.00 19428.30 105.59
AUD-92630-AUD REHAB PRELING HEARING LOSS 3 45.00 2870.33 63.79
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 117 113.75 5334.00 46.89
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 24 78.50 1450.00 18.47
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 3.00 137.50 45.83
CONOP-CONOP-CONSULT, OT, PHONE 2 0.50 12.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 8.25 400.00 48.48
CONPP-CONPP-CONSULT, PT, PHONE 11 5.50 112.50 20.45
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 9 30.25 268.75 8.88
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.00 50.00 25.00
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 507.75 25417.50 50.06
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 145 2110.50 95318.50 45.16
INTR-INTR-INTERPRETER 3 5.50 123.50 22.45
OCCT-97530-OT SESSION BY LICENSED OT 103 1439.50 78346.16 54.43
OCCT-97530HM-OT SESSION BY OT ASST 10 89.50 2697.58 30.14
PHY-97110-PT SESSION BY LICENSED PT 89 1182.00 67399.04 57.02
PHY-97110HM-PT SESSION BY PT ASST 7 33.50 1662.72 49.63
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 3 6.00 110.88 18.48
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 203 2752.50 170012.21 61.77
TRAN-TRAN-FAMILY TRANSPORTATION 2 180.00 90.00 0.50
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 729 407946 242737.16 0.60
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 1 23.00 1610.00 70.00
Subtotal (Total Children Is Unduplicated) 787 416753 716636.11 1.72
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Total 417407.00 756147.38 1.81
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Number of Children (Unduplicated) With at Least One Service 806
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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 8264 416657.00 742864.62 742868.62
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
139 750.00 13282.76 5.00
Other 0 0.00 0.00 0.00
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Total 8403 417407.00 756147.38 742873.62