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: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-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.00 31.86 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 47 53.00 467.09 8.81
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 55 66.00 711.96 10.79
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.00 23.67 7.89
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 55 60.04 1303.61 21.71
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 8 15.00 810.04 54.00
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 2.84 80.72 28.42
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 25 28.00 896.26 32.01
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 14.90 1117.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 36.45 2734.70 75.03
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 7.75 873.88 112.76
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.50 873.00 69.84
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 23.83 1787.50 75.01
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 9.88 479.84 48.57
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 41 43.59 2115.28 48.53
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 10 9.84 478.06 48.58
PSTH-97001-EVAL BY LICENSED PT, INITIAL 18 19.41 942.24 48.54
SPCH-92506-SPEECH EVAL BY LICENSED SLP 61 70.83 3405.52 48.08
Subtotal (Total Children Is Unduplicated) 217 485.36 19525.73 40.23
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AUD-HA_FUP-AUDIOLOGY SERVICES 4 5.00 246.00 49.20
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 2 2.00 100.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 2 0.75 18.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.00 50.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 1.75 87.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 29.50 1475.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 3 4.00 200.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 177 1372.17 92941.65 67.73
OCCT-97530HM-OT SESSION BY OT ASST 6 24.25 1317.26 54.32
PHY-97110-PT SESSION BY LICENSED PT 90 621.74 42291.52 68.02
SENS-V5264-EARMOLD 2 3.00 56.16 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 172 1245.86 84607.75 67.91
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 11 1215.00 1177.50 0.97
Subtotal (Total Children Is Unduplicated) 314 4526.27 224581.59 49.62
----------------------------------------------------------------------------------------------------------------
Total 5011.63 244107.32 48.71
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 402
----------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
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 4 2.86 415.18 309.49
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
2200 5008.77 243692.14 99.67
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2204 5011.63 244107.32 409.16