CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 3 3.00 31.86 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 20.00 176.60 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 30 32.00 345.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 25 26.00 566.54 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 2 2.00 108.76 54.38
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 7 7.00 197.96 28.28
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 10 12.00 358.74 29.90
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.00 46.80 46.80
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 2.00 239.20 119.60
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 3.00 375.00 125.00
EXIT-EXIT-TRANSITION ASSESSMENT 12 32.50 1625.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 10.00 750.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.50 112.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.50 262.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 12.50 693.75 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 46.00 3450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 28.00 2100.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 44.50 2469.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 22.50 1687.50 75.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.00 291.00 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.00 679.00 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.00 145.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.00 388.00 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 41 43.00 2085.50 48.50
Subtotal (Total Children Is Unduplicated) 190 393.00 19859.06 50.53
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 2.50 125.00 50.00
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 43 40.25 2012.50 50.00
CONIP-CONIP-CONSULT, ITDS, PHONE 5 2.75 68.75 25.00
CONOF-CONOF-CONSULT, OT, FACE TO FACE 23 21.75 1087.50 50.00
CONOP-CONOP-CONSULT, OT, PHONE 2 1.50 37.50 25.00
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 2.25 112.50 50.00
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 56 49.25 2462.50 50.00
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.00 50.00 25.00
ECE-ECE-EARLY CHILDHOOD EDUCATION 1 54.40 680.00 12.50
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 21 150.00 7512.50 50.08
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 171 1304.50 65225.00 50.00
INTR-INTR-INTERPRETER 11 83.00 4150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 145 835.36 56686.77 67.86
OCCT-97530HM-OT SESSION BY OT ASST 2 8.00 434.56 54.32
PHY-97110-PT SESSION BY LICENSED PT 83 434.50 29391.62 67.64
SENS-V5264-EARMOLD 1 1.00 18.72 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 230 1218.75 82728.75 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 26.50 1439.48 54.32
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 546 141643 99128.00 0.70
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 6 8.00 400.00 50.00
Subtotal (Total Children Is Unduplicated) 653 145889 353751.65 2.42
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Total 146282.26 373610.71 2.55
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Number of Children (Unduplicated) With at Least One Service 678
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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 2675 140611.49 278656.49 278656.49
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
716 5670.77 94954.22 0.00
Other 0 0.00 0.00 0.00
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Total 3391 146282.26 373610.71 278656.49