CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.750000 64.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.750000 64.7500 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 11 11.000000 216.8100 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 18.000000 235.7900 13.0994
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 17 18.000000 154.3600 8.5756
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 17.000000 473.1100 27.8300
AUDE-92586-AUD EVOKED RESPONSE (LIMITED) 1 2.000000 59.0600 29.5300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 83.5000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.000000 89.6000 22.4000
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 2 12.000000 576.8800 48.0733
EVAL-96111-DEVELOPMENTAL EVALUATION 2 5.500000 275.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 523.9600 55.1537
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 10.700000 802.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 25.000000 1365.3000 54.6120
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 108 200.161867 13290.0200 66.3964
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 98.458533 7384.3900 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 69.914800 5076.8000 72.6141
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 114 202.000000 10393.0900 51.4509
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 100.500000 7160.5000 71.2488
OCTF-97168-OT RE-EVAL EST PLAN CARE 8 8.000000 408.4000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 9 9.000000 399.4200 44.3800
OCTH-97166-OT EVAL MODERATE COMPLEXITY 15 14.000000 714.7000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 23 23.000000 1124.1500 48.8761
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 131.9400 32.9850
PSTH-97161-PT EVAL LOW COMPLEXITY 2 3.000000 109.2500 36.4167
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 23 22.832500 1145.6000 50.1741
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 45 44.469148 2230.1500 50.1505
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 10 10.000000 465.5000 46.5500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 3 3.000000 146.8200 48.9400
Subtotal (Total Children Is Unduplicated) 476 974.536848 56522.3500 57.9992
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 44.000000 3041.1000 69.1159
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.000000 146.6400 73.3200
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 20.000000 1000.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1147 7936.500000 396362.5000 49.9417
INTR-T1013-INTERPRETER 6 12.500000 625.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 415 2059.592386 138111.2992 67.0576
OCCT-97530HM-OT SESSION BY OT ASST 140 784.740304 44635.0000 56.8787
PHY-97110-PT SESSION BY LICENSED PT 398 2230.925400 147277.0100 66.0161
PHY-97110HM-PT SESSION BY PT ASST 30 198.944564 11364.4200 57.1236
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 1.000000 114.0000 114.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 884 5073.502463 339890.4103 66.9932
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 17.000000 972.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 4 9.699900 174.9200 18.0332
TRAV-TRAVS-Travel by mile 2 6.000000 2.6800 0.4467
Subtotal (Total Children Is Unduplicated) 2522 18411.90502 1084172.8795 58.8843
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Total 19388.191865 1140759.9795 58.8379
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Number of Children (Unduplicated) With at Least One Service 2765
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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 2718 2788.000000 149183.5900 149183.5900
D 69 68.250000 3185.2400 0.0000
S 66 70.000000 3726.6500 0.0000
H 3 4.500000 337.5000 0.0000
T 235 235.000000 12628.6500 12567.2100
3 3.000000 214.3200 0.0000
Other 34 45.000000 2790.2000 450.0000
---------------------------------------------------------
Total 3128 3213.750000 172066.1500 162200.8000
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 452 393.000000 25939.8600 25302.7300
13 8.000000 510.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 465 401.000000 26450.2100 25302.7300
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 158 156.500000 9325.8900 9325.8900
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
133 131.250000 7841.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 291 287.750000 17167.3300 9325.8900
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 115 236.000000 14126.3700 10763.4800
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 1.750000 64.7500 0.0000
Other 75 202.500000 13714.3100 0.0000
---------------------------------------------------------
Total 191 440.250000 27905.4300 10763.4800
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 47 88.000000 5968.0600 5968.0600
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 47 88.000000 5968.0600 5968.0600
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 2588 2173.750000 119661.7800 119661.7800
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
2382 1802.000000 103918.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4970 3975.750000 223579.8500 119661.7800
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 116 356.000000 23722.8600 23472.8600
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 116 356.000000 23722.8600 23472.8600
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.500000 112.5000 0.0000
P 169 429.000000 23225.8000 23225.8000
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
230 647.000000 46079.3800 0.0000
Other 22 38.500000 2887.5000 0.0000
---------------------------------------------------------
Total 422 1116.000000 72305.1800 23225.8000
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 332 574.500000 33754.4800 33754.4800
D 1 0.500000 35.7200 0.0000
S 1 1.500000 107.1600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
567 1108.500000 74492.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 901 1685.000000 108389.4600 33754.4800
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 447 1364.000000 92793.7600 92793.7600
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
10 24.000000 1714.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 457 1388.000000 94508.3200 92793.7600
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 409 835.500000 50263.4000 50263.4000
229 423.500000 24742.0900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 638 1259.000000 75005.4900 50263.4000
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 68 64.037512 3493.8600 3493.8600
T 44 47.000000 2578.9600 2578.9600
302 335.212480 17373.8492 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 414 446.249992 23446.6692 6072.8200
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 103 105.500000 5657.7200 5657.7200
T 46 48.500000 2606.9500 2606.9500
338 343.020000 19225.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 487 497.020000 27490.2000 8264.6700
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 879 834.750000 55442.5200 55442.5200
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
932 817.671873 54350.2103 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1811 1652.421873 109792.7303 55442.5200
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 23 13.000000 908.3300 908.3300
D 0 0.000000 0.0000 0.0000
S 2 11.000000 550.0000 550.0000
H 0 0.000000 0.0000 0.0000
T 699 2336.000000 117621.8200 117621.8200
122 222.000000 13881.8900 13606.8500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 846 2582.000000 132962.0400 132687.0000