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
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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 12.25 12.25
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.00 32.60 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 24 26.00 226.88 8.73
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 73 79.00 851.10 10.77
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 20 20.00 167.15 8.36
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 71 72.96 1575.30 21.59
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 4 5.00 271.90 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 31 30.16 852.52 28.27
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 18 18.00 583.74 32.43
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 212.00 106.00
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 20 23.60 1732.50 73.41
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 29 31.00 2287.50 73.79
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 22.00 1221.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 110 122.55 8927.80 72.85
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 191 205.75 15243.12 74.09
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 12.00 900.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 83.00 4606.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 82 94.67 7100.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 16 15.12 732.66 48.46
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 75 71.27 3455.06 48.48
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.16 571.97 47.04
PSTH-97001-EVAL BY LICENSED PT, INITIAL 24 22.59 1094.76 48.46
SPCH-92506-SPEECH EVAL BY LICENSED SLP 129 125.17 6068.95 48.49
Subtotal (Total Children Is Unduplicated) 587 1108.50 59739.76 53.89
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.00 236.58 118.29
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 28.50 1425.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 121 152.75 7637.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 21 7.75 193.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 44 41.25 2062.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 7 2.50 62.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 26 21.50 1075.00 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 124 163.50 8175.00 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 12 4.25 106.25 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 223 3877.25 179381.50 46.27
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 5.00 250.00 50.00
INTR-INTR-INTERPRETER 24 305.75 15287.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 240 3273.27 203764.45 62.25
OCCT-97530HM-OT SESSION BY OT ASST 2 4.00 217.28 54.32
PHY-97110-PT SESSION BY LICENSED PT 103 920.98 62207.93 67.55
PHY-97110HM-PT SESSION BY PT ASST 1 1.00 54.32 54.32
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 2.00 130.00 65.00
SENS-V5264-EARMOLD 3 8.00 149.76 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 277 3043.93 206571.88 67.86
TRAN-TRAN-FAMILY TRANSPORTATION 1 84.00 84.00 1.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 941 504757 464404.30 0.92
Subtotal (Total Children Is Unduplicated) 1099 517440 1190189.50 2.30
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Total 518548.93 1249929.26 2.41
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Number of Children (Unduplicated) With at Least One Service 1180
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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 11024 518547.18 1249868.97 1249868.97
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
25 1.75 60.29 0.00
Other 0 0.00 0.00 0.00
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Total 11049 518548.93 1249929.26 1249868.97