CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 2.000000 396.8000 198.4000
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.1000 56.1000
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 13.8000 13.8000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 28 29.000000 565.7900 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 30 31.000000 455.0800 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 32 33.000000 237.6000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 28 29.000000 838.6800 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 27 28.000000 589.1200 21.0400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.3200 45.3200
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 66.666667 4850.0000 72.7500
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 52 99.000000 7340.0000 74.1414
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 50.666667 3650.0000 72.0395
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 32 59.000000 4425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 12.500000 937.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 32 58.000000 4308.0000 74.2759
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 39.000000 2164.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 37 63.500000 3524.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 24.000000 1800.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 65.000000 4875.0000 75.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 50.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 6.505738 334.4600 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 13 13.000000 668.3300 51.4100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 14 16.000000 719.7400 44.9838
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 25 25.000000 1285.2500 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 12 12.000000 568.4800 47.3733
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 9 8.500000 360.3550 42.3947
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 43 43.000000 2210.6225 51.4098
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 27 29.000000 1388.0700 47.8645
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 11 40.000000 2089.2500 52.2313
Subtotal (Total Children Is Unduplicated) 445 932.339072 53652.7475 57.5464
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 9.000000 10721.2800 1191.2533
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.500000 75.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 9 8.250000 412.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 511 1825.250000 91062.5000 49.8904
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 67 152.000000 7600.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 368 1696.614237 119392.9700 70.3713
OCCT-97530GT-OT SESSION BY LICENSED OT 20 41.500000 2806.6800 67.6308
OCCT-97530HM-OT SESSION BY OT ASST 90 590.079860 32048.1700 54.3116
OCCT-97530HMGT-OT SESSION BY OT ASST 2 6.500000 374.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 353 1550.355054 105907.7600 68.3119
PHY-97110GT-PT SESSION BY LICENSED PT 26 64.750000 4153.6200 64.1486
PHY-97110HM-PT SESSION BY PT ASST 38 171.290131 9776.3100 57.0746
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 11 22.250000 1222.5500 54.9461
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 459.2200 459.2200
SENS-V5264-EARMOLD 2 4.000000 72.5200 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 734 3747.116748 258974.4400 69.1130
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 71 268.000000 18636.1800 69.5380
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 13.500000 777.6000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 2.000000 115.2000 57.6000
Subtotal (Total Children Is Unduplicated) 1843 10179.95603 664638.9000 65.2890
-----------------------------------------------------------------------------------------------------------------------
Total 11112.295102 718291.6475 64.6394
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2133
-----------------------------------------------------------------------------------------------------------------------
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 693 700.500000 41266.1900 41266.1900
D 35 37.000000 2147.6400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 917 924.000000 49762.4000 49628.8200
1 1.000000 50.0000 0.0000
Other 9 14.500000 1038.7500 0.0000
---------------------------------------------------------
Total 1655 1677.000000 94264.9800 90895.0100
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 394 313.750000 27320.2000 27320.2000
115 92.750000 7703.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 509 406.500000 35023.7000 27320.2000
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 46 50.000000 3085.1100 3085.1100
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
75 72.750000 4029.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 121 122.750000 7114.8000 3085.1100
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 75 141.500000 9184.2100 4815.1300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 27.8600 27.8600
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 38 78.000000 5489.5800 0.0000
---------------------------------------------------------
Total 114 220.500000 14701.6500 4842.9900
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 43 66.500000 3240.1500 3240.1500
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 2.000000 96.7500 96.7500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 45 68.500000 3336.9000 3336.9000
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 223 152.250000 9233.9600 9233.9600
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
648 487.250000 30571.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 871 639.500000 39805.8600 9233.9600
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 313 656.000000 45204.3000 45204.3000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 313 656.000000 45204.3000 45204.3000
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 339 1024.500000 72813.6700 72856.1500
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 150 454.500000 28877.7900 28877.7900
74 201.500000 14515.3000 0.0000
Other 27 50.500000 3787.5000 0.0000
---------------------------------------------------------
Total 590 1731.000000 119994.2600 101733.9400
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 1009 1633.250000 109387.8200 108698.3200
D 2 1.250000 89.9500 0.0000
S 18 18.000000 404.6200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
566 875.250000 56131.4175 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1595 2527.750000 166013.8075 108698.3200
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 131 366.750000 24485.8600 24485.8600
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
1 2.000000 143.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 132 368.750000 24629.7800 24485.8600
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 230 385.250000 22634.4000 22629.9000
283 485.000000 29198.9300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 513 870.250000 51833.3300 22629.9000
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 12 12.000000 621.9600 621.9600
91 99.000000 5639.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 103 111.000000 6261.4500 621.9600
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 110 115.010000 6308.7000 6308.7000
201 211.990000 11414.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 311 327.000000 17722.8300 6308.7000
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 248 250.000000 16172.8500 16172.8500
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
623 561.300484 36648.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 871 811.300484 52821.1600 16172.8500
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 33 42.537128 3012.9800 3089.6100
D 0 0.000000 0.0000 0.0000
S 5 11.500000 719.8000 719.8000
H 5 5.000000 97.9500 97.9500
T 103 262.957490 18698.5700 18698.5700
101 251.500000 16982.1300 16982.1300
Other 1 1.000000 51.4100 51.4100
---------------------------------------------------------
Total 248 574.494618 39562.8400 39639.4700