CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Agency Filter:EXT
Payclass Filters:TPIN
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 21.18 10.59
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 38.79 19.40
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 55.47 27.74
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 97.00 48.50
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.00 97.00 48.50
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 97.00 48.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 2.00 97.00 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 51 53.50 2500.00 46.73
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 12.82 599.92 46.80
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 23.73 1169.85 49.30
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.50 187.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 32 36.00 1746.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.72 859.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 52 56.80 2740.39 48.25
Subtotal (Total Children Is Unduplicated) 157 222.07 10470.87 47.15
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EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 2 1.90 94.84 49.92
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 33 252.88 12710.46 50.26
OCCT-97530-OT SESSION BY LICENSED OT 56 507.75 34353.36 67.66
PHY-97110-PT SESSION BY LICENSED PT 84 646.77 44203.35 68.34
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 1 1.44 721.55 501.08
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 188 1618.75 109970.35 67.94
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.50 19.80 13.20
Subtotal (Total Children Is Unduplicated) 274 3033.99 202165.47 66.63
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Total 3256.06 212636.34 65.30
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Number of Children (Unduplicated) With at Least One Service 306
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Center 52
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 27 43.94 2707.69 0.00
D 1 3.50 237.58 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
1764 3208.62 209691.07 0.00
Other 0 0.00 0.00 0.00
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Total 1792 3256.06 212636.34 0.00