CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 1.000000 14.8700 14.8700
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 25.2200 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 12.000000 91.0500 7.5875
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 11 11.000000 278.4100 25.3100
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 77.1300 77.1300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 74.2000 18.5500
EVAL-96111-DEVELOPMENTAL EVALUATION 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 15.000000 975.0000 65.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 98.144704 7156.1828 72.9146
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 51.378400 3853.3800 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 34 55.400000 4155.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 80 133.000000 7296.0400 54.8574
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 78.748999 5709.9056 72.5077
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 16 69.000000 3450.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 30 29.543976 1501.4100 50.8195
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 11 12.844858 583.8500 45.4540
PSTH-97163-PT EVAL HIGH COMPLEXITY 12 12.000000 612.6000 51.0500
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 60 61.000000 3044.0900 49.9031
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 379 703.060937 42085.8484 59.8609
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 28.000000 5372.9100 191.8896
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 0.500000 25.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 119.000000 5950.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 553 2720.250000 135778.1000 49.9138
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 2.000000 20.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 265 1147.703509 76814.9914 66.9293
OCCT-97530HM-OT SESSION BY OT ASST 112 601.410178 34222.1300 56.9031
PHY-97110-PT SESSION BY LICENSED PT 314 1459.842551 97254.7282 66.6200
PHY-97110HM-PT SESSION BY PT ASST 24 120.570200 6633.9200 55.0212
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5140-BEHIND EAR BINAURAL HEARING AID
1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 8 14.000000 252.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 700 3753.122511 260556.3661 69.4239
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 53.000000 2745.6000 51.8038
SPL-92508-GROUP SPL SESSION PER CHILD 3 3.500000 48.5800 13.8800
TRAV-TRAVS-Travel by mile 2 98.000000 43.6200 0.4451
Subtotal (Total Children Is Unduplicated) 1647 10126.89895 626781.9457 61.8928
-----------------------------------------------------------------------------------------------------------------------
Total 10829.959886 668867.7941 61.7609
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1856
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 1108 1135.750000 66524.2000 66524.2000
D 68 69.500000 3595.4800 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 306 308.750000 17903.2100 17903.2100
4 4.500000 305.3800 0.0000
Other 15 23.000000 1510.5000 0.0000
---------------------------------------------------------
Total 1501 1541.500000 89838.7700 84427.4100
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 2.000000 60.2200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 60.2200 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 11.000000 604.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 11.000000 604.7700 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 169 416.500000 25712.8400 25712.8400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.500000 178.6000 0.0000
T 0 0.000000 0.0000 0.0000
2 2.500000 171.4600 0.0000
Other 70 163.500000 11189.2800 945.2200
---------------------------------------------------------
Total 242 585.000000 37252.1800 26658.0600
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 94 180.250000 12448.5500 12448.5500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 94 180.250000 12448.5500 12448.5500
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 845 679.000000 37683.3000 37683.3000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
912 724.000000 41804.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1757 1403.000000 79488.1000 37683.3000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 255 492.250000 31725.5700 31725.5700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 3.000000 192.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 257 495.250000 31918.4500 31725.5700
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 176 489.000000 29071.4200 29071.4200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
303 861.500000 59253.6100 0.0000
Other 11 17.000000 1245.7500 0.0000
---------------------------------------------------------
Total 490 1367.500000 89570.7800 29071.4200
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
236 512.750000 34353.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 236 512.750000 34353.7800 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 301 1081.750000 70769.5800 70769.5800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
20 60.500000 4305.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 321 1142.250000 75074.8700 70769.5800
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 215 500.250000 31800.5700 31800.5700
152 291.250000 18389.5600 214.3200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 367 791.500000 50190.1300 32014.8900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 68 69.149800 3466.4800 3466.4800
236 254.849199 13187.3156 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 304 323.998999 16653.7956 3466.4800
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 114 117.500000 6598.8500 6598.8500
248 351.740000 14991.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 362 469.240000 21590.1400 6598.8500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 440 411.220044 28187.6400 28187.6400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
976 756.000843 50927.2585 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1416 1167.220887 79114.8985 28187.6400
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 30 33.273900 2271.2600 2271.2600
D 0 0.000000 0.0000 0.0000
S 5 7.726100 467.2400 467.2400
H 0 0.000000 0.0000 0.0000
T 122 367.500000 20079.5800 20079.5800
202 429.000000 27890.2800 27890.2800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 359 837.500000 50708.3600 50708.3600