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:MED
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) 16 16.00 141.28 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 17.00 183.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 20 25.00 544.75 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 5 5.00 159.05 31.81
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.00 90.00 45.00
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.00 230.00 115.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 8.50 637.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 10.50 787.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 16.00 888.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 43.50 3262.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 13.50 1012.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 60.00 3321.75 55.36
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 49 55.00 4125.00 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 16 17.00 824.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 33 37.00 1794.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 21 21.00 1018.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 77 81.00 3881.00 47.91
Subtotal (Total Children Is Unduplicated) 281 453.00 24307.13 53.66
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.00 75.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 224 3162.25 158075.00 49.99
OCCT-97530-OT SESSION BY LICENSED OT 130 1132.40 76866.24 67.88
OCCT-97530HM-OT SESSION BY OT ASST 24 351.50 18876.20 53.70
PHY-97110-PT SESSION BY LICENSED PT 110 998.75 67795.15 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 16.00 869.12 54.32
SENS-V5264-EARMOLD 2 3.00 56.16 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 199 1515.75 102821.23 67.84
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.50 59.40 13.20
Subtotal (Total Children Is Unduplicated) 450 7187.15 425493.50 59.20
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Total 7640.15 449800.63 58.87
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Number of Children (Unduplicated) With at Least One Service 547
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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 1 1.00 55.50 55.50
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
3179 7639.15 449745.13 0.00
Other 0 0.00 0.00 0.00
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Total 3180 7640.15 449800.63 55.50