CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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 4 4.000000 71.6800 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 21.3500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 75.6600 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 49.5600 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 151.8600 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 55.6500 18.5500
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.482800 336.2100 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.009777 150.7333 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 81 144.235201 10239.6000 70.9924
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 62.902934 4717.7200 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 75.500000 5625.6800 74.5123
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 57 97.500000 5300.2500 54.3615
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 35.000000 2532.7000 72.3629
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 15 72.000000 3600.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 2.312576 118.0600 51.0513
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 9 9.000000 444.1200 49.3467
OCTH-97167-OT EVAL HIGH COMPLEXITY 31 31.000000 1582.5500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 62.1000 31.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 17 16.979432 866.8000 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 51 52.000000 2654.6000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 7 6.979500 356.3000 51.0495
Subtotal (Total Children Is Unduplicated) 352 673.902220 41278.6833 61.2532
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 38.000000 10105.6000 265.9368
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 136.000000 6800.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 18.000000 745.2000 41.4000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 741 4243.650000 211678.1800 49.8812
INTR-T1013-INTERPRETER 2 4.500000 225.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 8.000000 80.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 270 1184.560399 81552.8698 68.8465
OCCT-97530HM-OT SESSION BY OT ASST 99 576.550350 32817.8800 56.9211
PHY-97110-PT SESSION BY LICENSED PT 307 1382.663013 89169.5336 64.4912
PHY-97110HM-PT SESSION BY PT ASST 25 96.048720 5518.7074 57.4574
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 786 7283.681844 294519.0200 40.4355
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 30.000000 1661.0000 55.3667
SPL-92508-GROUP SPL SESSION PER CHILD 5 16.000000 222.0800 13.8800
TRAV-TRAVS-Travel by mile 3 123.000000 54.7400 0.4450
Subtotal (Total Children Is Unduplicated) 1874 15150.15433 735662.3108 48.5581
-----------------------------------------------------------------------------------------------------------------------
Total 15824.056546 776940.9941 49.0987
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Number of Children (Unduplicated) With at Least One Service 2044
-----------------------------------------------------------------------------------------------------------------------
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 1562 1593.500000 90215.9700 90215.9700
D 215 217.000000 12410.9600 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 189 197.000000 10914.5900 10914.5800
2 2.000000 126.9400 0.0000
Other 7 10.000000 577.7600 0.0000
---------------------------------------------------------
Total 1975 2019.500000 114246.2200 101130.5500
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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 161 158.000000 10191.7600 10191.7600
17 9.500000 646.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 178 167.500000 10838.2800 10191.7600
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 66 138.500000 8222.9600 8222.9600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 7.500000 464.6000 0.0000
T 0 0.000000 0.0000 0.0000
3 2.000000 115.3500 0.0000
Other 64 117.500000 7680.2900 351.1300
---------------------------------------------------------
Total 135 265.500000 16483.2000 8574.0900
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 107 167.750000 11161.9200 11737.0800
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 107 167.750000 11161.9200 11737.0800
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 1465 1226.000000 67840.1200 67840.1200
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
1063 864.750000 47745.2100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2528 2090.750000 115585.3300 67840.1200
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 202 331.000000 20943.3100 20943.3100
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
1 0.750000 53.5800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 203 331.750000 20996.8900 20943.3100
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 218 576.000000 34500.8100 34500.8100
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
279 721.000000 51451.2400 0.0000
Other 20 32.000000 2400.0000 0.0000
---------------------------------------------------------
Total 517 1329.000000 88352.0500 34500.8100
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 64 96.500000 5220.3900 5220.3900
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
119 329.000000 24979.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 183 425.500000 30200.0400 5220.3900
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 315 4133.000000 74159.2900 74159.2900
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
33 96.500000 6582.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 348 4229.500000 80741.9100 74159.2900
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 385 823.500000 51221.5400 51221.5400
145 328.500000 20136.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 530 1152.000000 71358.2800 51221.5400
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 13 13.000000 650.0000 650.0000
T 11 11.000000 550.0000 550.0000
230 253.759777 13393.7633 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 254 277.759777 14593.7633 1200.0000
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 94 95.866800 5373.3442 5373.3400
T 15 14.500000 832.2000 832.2000
340 457.223198 19428.5692 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 449 567.589998 25634.1134 6205.5400
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 668 625.250000 43227.4700 43227.4700
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
863 727.456771 49257.6374 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1531 1352.706771 92485.1074 43227.4700
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 49 24.500000 1750.2800 1750.2800
D 0 0.000000 0.0000 0.0000
S 20 10.500000 728.6800 728.6800
H 0 0.000000 0.0000 0.0000
T 258 883.000000 46410.0400 46410.0400
286 529.250000 35374.8900 35571.3500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 613 1447.250000 84263.8900 84460.3500