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
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 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 16.00 141.28 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 21 23.00 248.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 17.00 370.43 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 3.00 163.14 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 1.84 52.44 28.50
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 8.00 254.48 31.81
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 10.00 750.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.33 25.00 75.76
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.00 111.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 0.33 25.00 75.76
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 5.00 242.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 12.00 582.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 13 12.13 557.50 45.96
Subtotal (Total Children Is Unduplicated) 58 120.63 4076.29 33.79
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.50 25.00 50.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.25 12.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 12.00 600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 59 260.62 17709.23 67.95
OCCT-97530HM-OT SESSION BY OT ASST 1 2.25 122.22 54.32
PHY-97110-PT SESSION BY LICENSED PT 35 138.59 9426.44 68.02
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 74 300.59 20492.49 68.17
Subtotal (Total Children Is Unduplicated) 118 714.80 48387.88 67.69
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Total 835.43 52464.17 62.80
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Number of Children (Unduplicated) With at Least One Service 144
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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 0 0.00 0.00 0.00
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
427 835.43 52464.17 0.00
Other 0 0.00 0.00 0.00
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Total 427 835.43 52464.17 0.00