CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
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 7.93 7.93
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.38 10.38
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 17.00 17.00
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.00 27.19 27.19
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 18.00 18.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 7 7.50 383.25 51.10
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 5 5.00 244.00 48.80
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 55.50 3579.50 64.50
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 10.00 436.50 43.65
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 9.00 463.00 51.44
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 1 1.00 50.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 76 101.50 5673.50 55.90
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 1100.00 550.00
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 10 11.50 575.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 1.50 75.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.50 12.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 2.75 137.50 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 2.00 100.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 3.00 150.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.50 12.50 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 5.50 275.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 10 11.25 763.65 67.88
PHY-97110-PT SESSION BY LICENSED PT 18 26.00 1764.88 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 0.50 33.94 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 58.02 3938.50 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.00 13.20 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 144 7527.38 3763.19 0.50
Subtotal (Total Children Is Unduplicated) 195 7653.40 12714.86 1.66
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Total 7754.90 18388.36 2.37
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Number of Children (Unduplicated) With at Least One Service 265
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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 0 0.00 0.00 0.00
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
444 7754.90 18388.36 0.00
Other 0 0.00 0.00 0.00
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Total 444 7754.90 18388.36 0.00