CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2008 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 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 22.00 194.26 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 44 46.00 496.80 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 9 9.00 75.96 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 43 44.00 958.76 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 15 15.00 424.20 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 11 12.00 381.72 31.81
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 0.60 75.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 10.50 787.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 8.00 600.00 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 2 2.00 150.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.00 499.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 30.00 2250.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 42.00 3150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.50 262.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 24.50 1359.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 30.50 2287.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 7.00 339.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 23 23.00 1115.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 8.00 388.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.00 533.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 70 70.00 3363.47 48.05
Subtotal (Total Children Is Unduplicated) 230 433.60 20017.18 46.17
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.50 25.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 48 48.50 2425.00 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 7 2.75 68.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 11.50 575.00 50.00
CONOP-CONOP-CONSULT, OT, PHONE 3 1.00 25.00 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 3.25 162.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 54 57.75 2887.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 9 164.50 8225.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 208 1472.25 73612.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 1.00 50.00 50.00
INTR-INTR-INTERPRETER 18 116.00 5800.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 161 1068.25 72512.81 67.88
OCCT-97530HM-OT SESSION BY OT ASST 2 5.25 285.18 54.32
PHY-97110-PT SESSION BY LICENSED PT 90 486.09 32989.68 67.87
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 281 1610.00 109371.67 67.93
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 514 140569 119547.20 0.85
Subtotal (Total Children Is Unduplicated) 666 145618 428562.79 2.94
----------------------------------------------------------------------------------------------------------------
Total 146051.19 448579.97 3.07
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 702
----------------------------------------------------------------------------------------------------------------
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 2906 143858.01 315435.90 315435.90
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
964 2193.18 133144.07 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3870 146051.19 448579.97 315435.90