CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 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 19 19.000000 368.7100 19.4058
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 23 24.000000 345.6600 14.4025
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 22 23.000000 238.0600 10.3504
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 26 27.000000 728.7400 26.9904
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 50.1000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 16 16.000000 321.4400 20.0900
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.000000 460.0000 115.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.000000 125.0000 125.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 25.031734 1877.3800 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 44 83.666667 6275.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 40 76.633333 5747.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 37 73.500000 5512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 51.500000 2858.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 87 160.500000 8907.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 23.500000 1762.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 43.500000 3262.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 567.7000 51.6091
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 29.000000 1480.4500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 6.000000 257.2300 42.8717
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 7 8.000000 350.0000 43.7500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 57 57.469148 2890.0400 50.2885
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 13 12.500000 638.1250 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 5 5.000000 222.7500 44.5500
Subtotal (Total Children Is Unduplicated) 425 833.300882 47987.4850 57.5872
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 6.000000 4750.8300 791.8050
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 717 4252.250000 212352.5000 49.9389
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 185 738.500000 36875.0000 49.9323
INTR-T1013-INTERPRETER 1 0.750000 37.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 13.000000 130.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 340 1447.279394 100374.7300 69.3541
OCCT-97530GT-OT SESSION BY LICENSED OT 60 178.500000 12590.8900 70.5372
OCCT-97530HM-OT SESSION BY OT ASST 99 502.532519 28423.2500 56.5600
OCCT-97530HMGT-OT SESSION BY OT ASST 7 21.000000 1201.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 350 1739.910273 119031.4999 68.4124
PHY-97110GT-PT SESSION BY LICENSED PT 37 124.750000 8852.3500 70.9607
PHY-97110HM-PT SESSION BY PT ASST 34 158.687720 9070.5900 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 3.000000 171.4800 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 2 4.000000 912.0000 228.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 835 4029.521555 279124.1498 69.2698
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 166 656.500000 46486.7000 70.8099
Subtotal (Total Children Is Unduplicated) 2203 13884.18146 860592.6697 61.9837
-----------------------------------------------------------------------------------------------------------------------
Total 14717.482343 908580.1547 61.7348
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2458
-----------------------------------------------------------------------------------------------------------------------
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 1751 1775.750000 98984.1500 98984.1500
D 185 185.250000 10182.7700 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1087 1101.500000 62081.5600 61753.4800
6 6.000000 300.0000 0.0000
Other 3 5.500000 344.2500 0.0000
---------------------------------------------------------
Total 3032 3074.000000 171892.7300 160737.6300
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 1 0.750000 53.5800 -17.8600
H 0 0.000000 0.0000 0.0000
T 391 308.750000 22149.4600 22149.4000
138 128.500000 8845.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 530 438.000000 31048.6000 22131.5400
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 4 4.000000 240.8500 240.8500
T 0 0.000000 0.0000 0.0000
57 57.000000 3657.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 61 61.000000 3897.8600 240.8500
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 51 116.500000 7249.4200 1517.1800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 34.000000 1764.8000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 145 348.500000 23605.1300 0.0000
---------------------------------------------------------
Total 205 499.000000 32619.3500 1517.1800
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 115 206.250000 12933.9700 12933.9700
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
32 62.250000 3781.5900 3781.5900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 147 268.500000 16715.5600 16715.5600
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 309 176.750000 12384.5300 12384.5300
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
1067 681.500000 46606.5800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1376 858.250000 58991.1100 12384.5300
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 204 466.250000 30336.7400 30336.7400
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 204 466.250000 30336.7400 30336.7400
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 114 270.000000 17676.8900 17676.8900
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
170 469.250000 33399.1400 0.0000
Other 39 77.500000 5198.2500 0.0000
---------------------------------------------------------
Total 323 816.750000 56274.2800 17676.8900
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 1131 1819.000000 123420.9600 123420.9600
D 1 4.500000 321.4800 0.0000
S 8 12.000000 592.9700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
444 899.750000 61823.3850 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1584 2735.250000 186158.7950 123420.9600
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 234 641.750000 42612.5900 42612.5900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 8.000000 485.7600 485.7600
T 0 0.000000 0.0000 0.0000
16 36.000000 2361.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 253 685.750000 45459.3500 43098.3500
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 357 702.000000 46117.1600 46021.3800
283 517.250000 31225.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 640 1219.250000 77342.9900 46021.3800
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 31 31.000000 1497.5400 1497.5400
118 125.500000 7150.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 149 156.500000 8647.7700 1497.5400
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 156 153.210000 7772.5000 7772.5000
186 197.290000 11108.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 342 350.500000 18880.7200 7772.5000
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 209 209.500000 14239.1300 14239.1300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 10.000000 721.5200 0.0000
T 0 0.000000 0.0000 0.0000
612 584.982343 37349.9997 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 830 804.482343 52310.6497 14239.1300
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 11 19.000000 957.3500 957.3500
H 0 0.000000 0.0000 0.0000
T 620 2071.000000 106197.2900 106197.2900
67 194.000000 10849.0100 10849.0100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 698 2284.000000 118003.6500 118003.6500