CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
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 848 3666.75 135605.00 36.98
Subtotal (Total Children Is Unduplicated) 848 3666.75 135605.00 36.98
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 11 11.00 91.73 8.34
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 11 11.00 116.28 10.57
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 10 10.00 189.16 18.92
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 27 34.00 2550.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 12.50 937.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 20 25.00 1875.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 34 47.50 3525.00 74.21
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 45 56.00 3108.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 46.00 3450.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 23.50 1762.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 49 59.00 4425.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 96 113.00 6271.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 134 165.00 12375.00 75.00
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.00 34.01 34.01
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.00 186.13 62.04
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 18 18.00 1328.23 73.79
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 15 17.00 890.17 52.36
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 24 29.00 1450.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 279 698.50 46144.77 66.06
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 77.50 3858.25 49.78
OCCT-97530-OT SESSION BY LICENSED OT 4 23.50 1595.18 67.88
PHY-97110-PT SESSION BY LICENSED PT 5 45.50 3088.43 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 72.00 4887.36 67.88
Subtotal (Total Children Is Unduplicated) 31 218.50 13429.22 61.46
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Total 4583.75 195178.99 42.58
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Number of Children (Unduplicated) With at Least One Service 853
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Center 01
Flag Claims Units Chgs Paid
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R 2 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 229 164.00 8656.50 0.00
P 332 192.75 7340.00 7293.75
D 129 72.00 2664.00 0.00
S 87 74.50 2870.00 0.00
H 1 1.00 75.00 0.00
T 14 14.00 995.75 995.75
49 55.50 3149.05 0.00
Other 665 394.75 16291.50 0.00
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Total 1508 969.00 42060.30 8289.50
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.50 18.50 0.00
U 0 0.00 0.00 0.00
B 0 164.00 8656.50 0.00
P 8 196.00 7460.25 7414.00
D 0 72.00 2664.00 0.00
S 0 74.50 2870.00 0.00
H 0 1.00 75.00 0.00
T 0 14.00 995.75 995.75
0 55.50 3149.05 0.00
Other 0 394.75 16291.50 0.00
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Total 8 972.25 42180.55 8409.75
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 1.25 46.25 0.00
U 0 0.00 0.00 0.00
B 159 281.75 13094.25 0.00
P 725 686.00 26036.25 25658.84
D 2 74.00 2756.50 37.00
S 0 74.50 2870.00 0.00
H 7 23.00 1175.00 1100.00
T 0 14.00 995.75 995.75
5 59.75 3750.30 0.00
Other 0 394.75 16291.50 0.00
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Total 899 1609.00 67015.80 27791.59
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 20 21.25 1165.34 0.00
U 0 0.00 0.00 0.00
B 1061 892.75 36268.27 200.00
P 0 686.00 26036.25 25658.84
D 0 74.00 2756.50 37.00
S 0 74.50 2870.00 0.00
H 0 23.00 1175.00 1100.00
T 0 14.00 995.75 995.75
56 101.25 6466.35 0.00
Other 0 394.75 16291.50 0.00
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Total 1137 2281.50 94024.96 27991.59
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 21.25 1165.34 0.00
U 0 0.00 0.00 0.00
B 636 1254.00 49634.52 255.50
P 297 850.75 32132.00 31754.59
D 0 74.00 2756.50 37.00
S 0 74.50 2870.00 0.00
H 0 23.00 1175.00 1100.00
T 0 14.00 995.75 995.75
83 186.75 10357.16 0.00
Other 0 394.75 16291.50 0.00
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Total 1016 2893.00 117377.77 34142.84
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 21.25 1165.34 0.00
U 0 0.00 0.00 0.00
B 5 1256.75 49736.27 255.50
P 39 890.00 33849.25 33471.84
D 0 74.00 2756.50 37.00
S 0 74.50 2870.00 0.00
H 0 23.00 1175.00 1100.00
T 0 14.00 995.75 995.75
0 186.75 10357.16 0.00
Other 0 394.75 16291.50 0.00
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Total 44 2935.00 119196.77 35860.09
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 21.25 1165.34 0.00
U 0 0.00 0.00 0.00
B 820 2014.25 81428.27 255.50
P 456 1385.25 59183.50 58804.59
D 15 93.50 3478.00 758.50
S 0 74.50 2870.00 0.00
H 0 23.00 1175.00 1100.00
T 0 14.00 995.75 995.75
3 189.75 10560.80 0.00
Other 1 397.00 16374.75 0.00
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Total 1295 4212.50 177231.41 61914.34
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 21.25 1165.34 0.00
U 0 0.00 0.00 0.00
B 87 2072.25 83612.27 255.50
P 0 1385.25 59183.50 58804.59
D 0 93.50 3478.00 758.50
S 0 74.50 2870.00 0.00
H 0 23.00 1175.00 1100.00
T 0 14.00 995.75 995.75
34 262.25 15298.16 0.00
Other 0 397.00 16374.75 0.00
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Total 121 4343.00 184152.77 61914.34
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 21.25 1165.34 0.00
U 0 0.00 0.00 0.00
B 47 2106.00 85002.77 255.50
P 33 1406.00 60056.75 59677.74
D 0 93.50 3478.00 758.50
S 0 74.50 2870.00 0.00
H 0 23.00 1175.00 1100.00
T 0 14.00 995.75 995.75
4 266.25 15493.66 0.00
Other 0 397.00 16374.75 0.00
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Total 84 4401.50 186612.02 62787.49
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 10 27.25 1387.34 0.00
U 0 0.00 0.00 0.00
B 1 2106.25 85012.02 255.50
P 24 1426.00 61103.50 60724.49
D 10 100.25 3784.75 758.50
S 0 74.50 2870.00 0.00
H 0 23.00 1175.00 1100.00
T 0 14.00 995.75 995.75
0 266.25 15493.66 0.00
Other 0 397.00 16374.75 0.00
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Total 45 4434.50 188196.77 63834.24
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.25 1387.34 0.00
U 0 0.00 0.00 0.00
B 70 2141.50 86316.27 255.50
P 125 1488.25 63530.00 63150.99
D 0 100.25 3784.75 758.50
S 0 74.50 2870.00 0.00
H 0 23.00 1175.00 1100.00
T 0 14.00 995.75 995.75
23 309.25 18364.88 0.00
Other 0 397.00 16374.75 0.00
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Total 218 4575.00 194798.74 66260.74
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.25 1387.34 0.00
U 0 0.00 0.00 0.00
B 1 2141.75 86325.52 255.50
P 4 1494.50 63761.25 63382.24
D 0 100.25 3784.75 758.50
S 1 74.75 2879.25 0.00
H 0 23.00 1175.00 1100.00
T 0 14.00 995.75 995.75
2 311.25 18495.38 0.00
Other 0 397.00 16374.75 0.00
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Total 8 4583.75 195178.99 66491.99