CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2008 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 354 727.25 26889.75 36.97
Subtotal (Total Children Is Unduplicated) 354 727.25 26889.75 36.97
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.00 450.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.50 187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.00 337.50 67.50
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.50 194.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 14.50 1087.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.50 562.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 17.00 1275.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 12.00 666.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 27.50 2062.50 75.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 4 4.00 200.60 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 55 116.00 7659.17 66.03
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 26.00 1300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.00 67.88 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 5.50 373.34 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 25.50 1730.94 67.88
Subtotal (Total Children Is Unduplicated) 15 58.00 3472.16 59.86
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Total 901.25 38021.08 42.19
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Number of Children (Unduplicated) With at Least One Service 358
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Center 01
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 53 32.25 1193.25 0.00
P 0 0.00 0.00 0.00
D 16 13.00 481.00 0.00
S 52 35.75 1322.75 0.00
H 1 1.00 75.00 0.00
T 0 0.00 0.00 0.00
23 19.25 973.09 0.00
Other 157 115.75 5658.50 0.00
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Total 302 217.00 9703.59 0.00
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 0.75 27.75 0.00
U 0 0.00 0.00 0.00
B 111 118.00 4452.50 0.00
P 59 38.75 1490.25 1490.25
D 0 13.00 481.00 0.00
S 0 35.75 1322.75 0.00
H 2 9.00 475.00 400.00
T 0 0.00 0.00 0.00
2 20.50 1019.34 0.00
Other 0 115.75 5658.50 0.00
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Total 175 351.50 14927.09 1890.25
Center 05
Flag Claims Units Chgs Paid
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R 7 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 295 277.00 10335.50 0.00
P 0 38.75 1490.25 1490.25
D 0 13.00 481.00 0.00
S 0 35.75 1322.75 0.00
H 0 9.00 475.00 400.00
T 0 0.00 0.00 0.00
16 34.00 1962.12 0.00
Other 0 115.75 5658.50 0.00
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Total 318 531.00 22175.95 1890.25
Center 06
Flag Claims Units Chgs Paid
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R 0 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 238 414.50 15423.00 0.00
P 0 38.75 1490.25 1490.25
D 0 13.00 481.00 0.00
S 0 35.75 1322.75 0.00
H 0 9.00 475.00 400.00
T 0 0.00 0.00 0.00
46 81.00 4590.82 0.00
Other 0 115.75 5658.50 0.00
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Total 284 715.50 29892.15 1890.25
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 63 463.50 17282.25 0.00
P 5 45.75 2015.25 2015.25
D 0 13.00 481.00 0.00
S 0 35.75 1322.75 0.00
H 0 9.00 475.00 400.00
T 0 0.00 0.00 0.00
0 81.00 4590.82 0.00
Other 0 115.75 5658.50 0.00
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Total 68 771.50 32276.40 2415.25
Center 51
Flag Claims Units Chgs Paid
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R 0 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 36 491.50 18318.25 0.00
P 0 45.75 2015.25 2015.25
D 0 13.00 481.00 0.00
S 0 35.75 1322.75 0.00
H 0 9.00 475.00 400.00
T 0 0.00 0.00 0.00
9 96.00 5536.00 0.00
Other 0 115.75 5658.50 0.00
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Total 45 814.50 34257.58 2415.25
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 450.83 0.00
U 0 0.00 0.00 0.00
B 3 492.25 18346.00 0.00
P 9 52.75 2349.75 2349.75
D 0 13.00 481.00 0.00
S 0 35.75 1322.75 0.00
H 0 9.00 475.00 400.00
T 0 0.00 0.00 0.00
0 96.00 5536.00 0.00
Other 0 115.75 5658.50 0.00
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Total 12 822.25 34619.83 2749.75
Center 53
Flag Claims Units Chgs Paid
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R 4 10.00 534.08 0.00
U 0 0.00 0.00 0.00
B 0 492.25 18346.00 0.00
P 19 68.25 3145.25 3145.25
D 8 19.00 760.00 0.00
S 0 35.75 1322.75 0.00
H 0 9.00 475.00 400.00
T 0 0.00 0.00 0.00
0 96.00 5536.00 0.00
Other 0 115.75 5658.50 0.00
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Total 31 846.00 35777.58 3545.25
Center 54
Flag Claims Units Chgs Paid
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R 0 10.00 534.08 0.00
U 0 0.00 0.00 0.00
B 29 508.00 18928.75 0.00
P 46 93.50 4070.25 4070.25
D 0 19.00 760.00 0.00
S 0 35.75 1322.75 0.00
H 0 9.00 475.00 400.00
T 0 0.00 0.00 0.00
6 101.50 5891.50 0.00
Other 0 115.75 5658.50 0.00
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Total 81 892.50 37640.83 4470.25
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 10.00 534.08 0.00
U 0 0.00 0.00 0.00
B 1 508.25 18938.00 0.00
P 4 99.75 4301.50 4301.50
D 0 19.00 760.00 0.00
S 1 36.00 1332.00 0.00
H 0 9.00 475.00 400.00
T 0 0.00 0.00 0.00
2 103.50 6022.00 0.00
Other 0 115.75 5658.50 0.00
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Total 8 901.25 38021.08 4701.50