CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 4.00 44.11 11.03
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 85 95.00 835.25 8.79
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 135 162.00 1746.66 10.78
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 24 24.00 199.26 8.30
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 143 158.00 3423.66 21.67
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 14 22.00 1190.70 54.12
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 33 33.00 933.24 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 46 51.00 1639.05 32.14
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.00 90.00 45.00
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.00 442.00 110.50
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 3 3.00 375.00 125.00
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.50 37.50 75.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 37 47.00 3487.50 74.20
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 33 35.00 2587.50 73.93
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 5.00 375.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 17.00 1275.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 39.00 2164.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 169 202.50 14925.00 73.70
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 207 227.00 17129.50 75.46
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 21.00 1575.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 116 155.50 8801.25 56.60
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 151 173.50 13012.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 40 42.00 2037.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 139 151.86 7364.84 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 26 30.00 1438.03 47.93
PSTH-97001-EVAL BY LICENSED PT, INITIAL 60 63.00 3055.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 259 277.00 13355.47 48.21
Subtotal (Total Children Is Unduplicated) 876 2046.86 103572.62 50.60
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 236.58 118.29
AUD-HA_FUP-AUDIOLOGY SERVICES 4 5.00 246.00 49.20
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 28.50 1425.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 123 154.75 7737.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 23 8.50 212.50 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 45 42.25 2112.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 7 2.50 62.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 27 21.75 1087.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 126 165.25 8262.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 12 4.25 106.25 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.00 75.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 16 734.25 36712.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 414 7069.00 338931.50 47.95
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 9.00 450.00 50.00
INTR-INTR-INTERPRETER 24 305.75 15287.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 390 5777.84 373572.34 64.66
OCCT-97530HM-OT SESSION BY OT ASST 32 379.75 20410.74 53.75
PHY-97110-PT SESSION BY LICENSED PT 221 2541.47 172294.60 67.79
PHY-97110HM-PT SESSION BY PT ASST 3 17.00 923.44 54.32
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.00 130.00 65.00
SENS-V5264-EARMOLD 7 14.00 262.08 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 526 5805.54 394000.86 67.87
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.50 59.40 13.20
TRAN-TRAN-FAMILY TRANSPORTATION 1 84.00 84.00 1.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 941 505972 465581.80 0.92
Subtotal (Total Children Is Unduplicated) 1204 529154 1840264.59 3.48
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Total 531200.71 1943837.21 3.66
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Number of Children (Unduplicated) With at Least One Service 1295
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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 11029 518551.04 1250339.65 1250233.96
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
5404 12649.67 693497.56 99.67
Other 0 0.00 0.00 0.00
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Total 16433 531200.71 1943837.21 1250333.63