CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:MED
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 721 2578.50 95090.00 36.88
Subtotal (Total Children Is Unduplicated) 721 2578.50 95090.00 36.88
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 10 10.00 88.30 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.00 86.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 10 10.00 217.90 21.79
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 11.50 825.00 71.74
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 7.50 562.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 13.00 721.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 145 189.50 14212.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 67 109.00 8175.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 81 94.50 7061.00 74.72
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 207 301.00 16705.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 88 112.50 8412.50 74.78
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.00 3515.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 114.54 57.27
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 15 15.00 750.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 363 916.50 62324.70 68.00
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.50 175.00 50.00
Subtotal (Total Children Is Unduplicated) 1 3.50 175.00 50.00
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Total 3498.50 157589.70 45.04
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Number of Children (Unduplicated) With at Least One Service 756
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 74 66.25 2451.25 0.00
H 2 3.00 195.75 0.00
T 10 12.50 801.00 801.00
22 25.00 1413.25 0.00
Other 287 224.25 8514.00 0.00
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Total 395 331.00 13375.25 801.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 70 70.25 2599.25 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 66.25 2451.25 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
2 28.50 1580.75 0.00
Other 0 224.25 8514.00 0.00
-------------------------------------------------
Total 72 404.75 16142.00 801.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 21 96.75 4061.00 0.00
P 106 93.50 3459.50 3459.50
D 0 0.00 0.00 0.00
S 0 66.25 2451.25 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
8 36.50 2009.75 0.00
Other 7 231.25 8616.66 0.00
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Total 142 539.75 21594.91 4260.50
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 213 404.25 15569.00 0.00
P 24 112.00 4989.00 4718.31
D 5 5.00 277.50 0.00
S 0 66.25 2451.25 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
19 58.50 5339.75 0.00
Other 0 231.25 8616.66 0.00
-------------------------------------------------
Total 261 892.75 38239.91 5519.31
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 93 472.25 18085.00 0.00
P 0 112.00 4989.00 4718.31
D 0 5.00 277.50 0.00
S 0 66.25 2451.25 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
7 66.50 5891.00 0.00
Other 0 231.25 8616.66 0.00
-------------------------------------------------
Total 100 968.75 41307.16 5519.31
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 165 601.25 22858.00 0.00
P 0 112.00 4989.00 4718.31
D 0 5.00 277.50 0.00
S 0 66.25 2451.25 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
49 117.25 8159.79 0.00
Other 0 231.25 8616.66 0.00
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Total 214 1148.50 48348.95 5519.31
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 186 758.50 28917.00 0.00
P 12 133.00 6534.75 6264.06
D 0 5.00 277.50 0.00
S 12 78.50 3015.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
5 124.50 8557.54 0.00
Other 0 231.25 8616.66 0.00
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Total 215 1346.25 56915.70 7065.06
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 1.00 50.00 0.00
U 0 0.00 0.00 0.00
B 26 791.00 30837.50 75.00
P 316 542.75 27585.75 27315.06
D 0 5.00 277.50 0.00
S 0 78.50 3015.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
16 141.50 9725.29 0.00
Other 0 231.25 8616.66 0.00
-------------------------------------------------
Total 359 1806.50 81104.95 28191.06
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 50.00 0.00
U 0 0.00 0.00 0.00
B 450 1202.50 46326.00 75.00
P 138 749.75 41593.75 41323.06
D 10 17.50 986.00 708.50
S 0 78.50 3015.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
0 141.50 9725.29 0.00
Other 0 231.25 8616.66 0.00
-------------------------------------------------
Total 598 2437.50 111309.95 42907.56
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 50.00 0.00
U 0 0.00 0.00 0.00
B 174 1333.25 51315.75 75.00
P 0 749.75 41593.75 41323.06
D 0 17.50 986.00 708.50
S 0 78.50 3015.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
10 151.50 10377.79 0.00
Other 0 231.25 8616.66 0.00
-------------------------------------------------
Total 184 2578.25 116952.20 42907.56
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 50.00 0.00
U 0 0.00 0.00 0.00
B 147 1459.75 56974.75 75.00
P 19 758.00 41899.00 41628.31
D 0 17.50 986.00 708.50
S 0 78.50 3015.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
4 155.50 10577.79 0.00
Other 0 231.25 8616.66 0.00
-------------------------------------------------
Total 170 2717.00 123116.45 43212.81
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 9 5.00 198.00 0.00
U 0 0.00 0.00 0.00
B 40 1499.50 58559.00 75.00
P 0 758.00 41899.00 41628.31
D 0 17.50 986.00 708.50
S 0 78.50 3015.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
17 181.50 12136.79 0.00
Other 0 231.25 8616.66 0.00
-------------------------------------------------
Total 66 2786.75 126407.70 43212.81
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 5.00 198.00 0.00
U 0 0.00 0.00 0.00
B 268 1697.25 65944.50 75.00
P 102 843.75 44979.25 44616.06
D 0 17.50 986.00 708.50
S 0 78.50 3015.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
46 235.50 15343.29 0.00
Other 0 231.25 8616.66 0.00
-------------------------------------------------
Total 416 3124.25 140079.95 46200.56
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 5.00 198.00 0.00
U 0 0.00 0.00 0.00
B 10 1709.75 66464.00 75.00
P 108 966.50 49673.50 49310.31
D 0 17.50 986.00 708.50
S 0 78.50 3015.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
52 323.25 20845.04 0.00
Other 0 231.25 8616.66 0.00
-------------------------------------------------
Total 170 3347.25 150795.45 50894.81
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 5.00 198.00 0.00
U 0 0.00 0.00 0.00
B 62 1798.25 69738.50 75.00
P 17 986.25 50404.25 50041.06
D 0 17.50 986.00 708.50
S 0 78.50 3015.50 0.00
H 0 3.00 195.75 0.00
T 0 12.50 801.00 801.00
43 366.25 23634.04 0.00
Other 0 231.25 8616.66 0.00
-------------------------------------------------
Total 122 3498.50 157589.70 51625.56