CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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 10 11.000000 213.4100 19.4009
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 17.000000 242.8900 14.2876
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.5000 23.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 18 19.000000 180.3300 9.4911
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 17.000000 482.0100 28.3535
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 44.7600 44.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 8.000000 168.6300 21.0788
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 56.500000 4237.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 79 146.500000 10686.3300 72.9442
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 18.500000 1237.5000 66.8919
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 42.500000 3137.5000 73.8235
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 37.500000 2812.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 59.000000 3274.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 111 195.500000 10756.8100 55.0220
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 15.000000 1125.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 37.000000 2775.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 2.602742 132.8700 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 109.6500 36.5500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 24 25.000000 1225.2000 49.0080
OCTH-97167-OT EVAL HIGH COMPLEXITY 13 22.000000 1123.1000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 5.696376 290.8000 51.0500
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 43 43.000000 2134.3100 49.6351
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 10 13.000000 612.6000 47.1231
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 31.5200 31.5200
Subtotal (Total Children Is Unduplicated) 397 855.799118 50561.8700 59.0815
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 9.000000 4808.2600 534.2511
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 18 18.000000 900.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 845 4527.250000 226172.5000 49.9580
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 218 762.250000 38112.5000 50.0000
INTR-T1013-INTERPRETER 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 12.000000 120.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 341 1277.740617 87594.4600 68.5542
OCCT-97530GT-OT SESSION BY LICENSED OT 51 115.500000 8022.8300 69.4617
OCCT-97530HM-OT SESSION BY OT ASST 103 439.009614 24582.6900 55.9958
OCCT-97530HMGT-OT SESSION BY OT ASST 6 21.500000 1233.9700 57.3940
PHY-97110-PT SESSION BY LICENSED PT 331 1279.240342 86637.5900 67.7258
PHY-97110GT-PT SESSION BY LICENSED PT 45 122.500000 8446.7600 68.9531
PHY-97110HM-PT SESSION BY PT ASST 44 207.357767 11640.6700 56.1381
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 2.000000 114.3200 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 1 8.000000 571.5200 71.4400
SENS-V5264-EARMOLD 2 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 792 3396.006861 234232.6800 68.9730
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 122 401.750000 28555.8600 71.0787
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 40.500000 2316.6000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.6800 13.6800
Subtotal (Total Children Is Unduplicated) 2271 12647.60520 764373.7700 60.4362
-----------------------------------------------------------------------------------------------------------------------
Total 13503.404319 814935.6400 60.3504
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2526
-----------------------------------------------------------------------------------------------------------------------
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 1662 1684.750000 90626.0700 90566.0700
D 104 104.500000 6091.4900 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 614 628.750000 34425.6700 33968.3750
1 1.000000 50.0000 0.0000
Other 15 27.500000 1887.0000 0.0000
---------------------------------------------------------
Total 2396 2446.500000 133080.2300 124534.4450
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 616 538.000000 34536.1100 34536.1100
107 81.000000 4861.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 723 619.000000 39397.7400 34536.1100
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
108 108.000000 6421.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 108 108.000000 6421.3000 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 17 45.250000 2619.7500 2691.1900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 20.000000 1040.3500 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 67 142.000000 9689.4400 595.0600
---------------------------------------------------------
Total 89 207.250000 13349.5400 3286.2500
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 106 176.000000 10098.9800 10098.9800
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
3 3.500000 86.7800 86.7800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 109 179.500000 10185.7600 10185.7600
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 492 328.750000 20909.5900 20909.5900
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
680 492.750000 32781.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1172 821.500000 53690.5900 20909.5900
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 228 443.750000 28732.4700 28732.4700
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 228 443.750000 28732.4700 28732.4700
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 105 288.000000 19727.2600 19727.2600
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
134 372.500000 26624.8300 0.0000
Other 31 58.000000 4125.7500 0.0000
---------------------------------------------------------
Total 270 718.500000 50477.8400 19727.2600
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 1023 1751.750000 114324.5000 114003.0200
D 0 0.000000 0.0000 0.0000
S 10 14.000000 979.7700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
491 777.750000 52226.2900 240.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1524 2543.500000 167530.5600 114243.0200
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 190 476.750000 31446.8700 31446.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 3.000000 214.3200 214.3200
T 0 0.000000 0.0000 0.0000
13 31.250000 2165.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 204 511.000000 33826.9400 31661.1900
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 392 729.750000 45699.4900 45699.4900
307 576.750000 34855.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 699 1306.500000 80554.8500 45699.4900
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 20 20.000000 1292.0000 1292.0000
157 162.000000 8822.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 177 182.000000 10114.7600 1292.0000
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 0 0.000000 0.0000 0.0000
T 167 171.830000 9800.0500 9800.0500
177 192.420000 11240.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 344 364.250000 21040.0500 9800.0500
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 177 167.866784 11132.5700 11132.5700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
526 507.287535 32872.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 704 677.154319 44155.0700 11132.5700
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 1 2.000000 142.8800 144.0000
D 0 0.000000 0.0000 0.0000
S 7 12.250000 675.0600 675.0600
H 0 0.000000 0.0000 0.0000
T 611 2036.000000 103340.6900 103340.6900
92 324.750000 18219.3100 18219.3100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 711 2375.000000 122377.9400 122379.0600