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: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 783 2573.50 95090.00 36.95
Subtotal (Total Children Is Unduplicated) 783 2573.50 95090.00 36.95
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Screening, Eval, and Assessment,Class #02
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.00 16.30 16.30
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.00 26.49 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.00 65.37 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.00 900.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 5.50 412.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 8.50 637.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 18.50 1026.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 175 223.50 16762.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 86 135.50 10125.00 74.72
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 67 83.00 6225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 191 272.00 15096.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 98 166.50 12487.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.00 2960.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 51 51.00 2550.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 425 1011.00 70130.21 69.37
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Total 3584.50 165220.21 46.09
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Number of Children (Unduplicated) With at Least One Service 805
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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 82 94.75 3505.75 0.00
P 0 0.00 0.00 0.00
D 27 28.75 1063.75 0.00
S 36 42.75 1581.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
18 22.00 1383.00 0.00
Other 143 154.00 6392.00 0.00
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Total 306 342.25 13926.25 0.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 6.75 249.75 0.00
U 0 0.00 0.00 0.00
B 50 142.50 5272.50 0.00
P 0 0.00 0.00 0.00
D 0 28.75 1063.75 0.00
S 0 42.75 1581.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
20 57.25 3319.50 0.00
Other 0 154.00 6392.00 0.00
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Total 76 432.00 17879.25 0.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 8.75 323.75 0.00
U 0 0.00 0.00 0.00
B 86 224.50 8769.75 0.00
P 112 98.00 3956.25 3943.25
D 0 28.75 1063.75 0.00
S 0 42.75 1581.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 58.75 3375.00 0.00
Other 8 162.00 6510.96 0.00
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Total 213 623.50 25581.21 3943.25
Center 04
Flag Claims Units Chgs Paid
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R 3 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 189 479.50 19413.00 0.00
P 49 167.75 6613.00 6600.00
D 0 28.75 1063.75 0.00
S 0 42.75 1581.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
17 77.50 6356.75 0.00
Other 0 162.00 6510.96 0.00
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Total 258 976.00 42195.96 6600.00
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 50 510.00 20541.50 0.00
P 0 167.75 6613.00 6600.00
D 0 28.75 1063.75 0.00
S 0 42.75 1581.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 80.00 6515.00 0.00
Other 0 162.00 6510.96 0.00
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Total 52 1009.00 43482.71 6600.00
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 194 649.00 25684.50 0.00
P 0 167.75 6613.00 6600.00
D 0 28.75 1063.75 0.00
S 0 42.75 1581.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
53 130.25 9628.25 0.00
Other 0 162.00 6510.96 0.00
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Total 247 1198.25 51738.96 6600.00
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 17.75 656.75 0.00
U 0 0.00 0.00 0.00
B 135 784.50 31633.75 0.00
P 87 261.50 10963.75 10950.75
D 1 29.25 1082.25 0.00
S 9 53.25 2118.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8 144.25 10493.00 0.00
Other 0 162.00 6510.96 0.00
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Total 240 1452.50 63458.71 10950.75
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 19.25 712.25 0.00
U 0 0.00 0.00 0.00
B 29 823.25 33909.50 0.00
P 315 661.25 31455.25 31442.25
D 0 29.25 1082.25 0.00
S 0 53.25 2118.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1 146.25 10643.00 0.00
Other 0 162.00 6510.96 0.00
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Total 347 1894.50 86431.46 31442.25
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 19.25 712.25 0.00
U 0 0.00 0.00 0.00
B 362 1161.00 46738.00 0.00
P 124 842.75 44463.25 44450.25
D 2 30.25 1119.25 37.00
S 12 62.00 2442.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 146.25 10643.00 0.00
Other 0 162.00 6510.96 0.00
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Total 500 2423.50 112628.71 44487.25
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 19.25 712.25 0.00
U 0 0.00 0.00 0.00
B 177 1326.50 52975.50 0.00
P 0 842.75 44463.25 44450.25
D 0 30.25 1119.25 37.00
S 0 62.00 2442.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
23 172.75 12574.75 0.00
Other 0 162.00 6510.96 0.00
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Total 200 2615.50 120797.96 44487.25
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 19.25 712.25 0.00
U 0 0.00 0.00 0.00
B 91 1392.75 55493.00 0.00
P 68 897.75 47004.25 46991.25
D 0 30.25 1119.25 37.00
S 0 62.00 2442.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
12 189.25 13709.25 0.00
Other 0 162.00 6510.96 0.00
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Total 171 2753.25 126990.96 47028.25
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 11 38.25 1415.25 0.00
U 0 0.00 0.00 0.00
B 1 1393.75 55530.00 0.00
P 78 1008.75 53462.00 53448.50
D 38 75.00 3049.75 37.00
S 0 62.00 2442.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 189.25 13709.25 0.00
Other 0 162.00 6510.96 0.00
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Total 128 2929.00 136119.21 53485.50
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 38.25 1415.25 0.00
U 0 0.00 0.00 0.00
B 165 1513.75 60092.75 0.00
P 251 1171.75 59570.50 59557.00
D 0 75.00 3049.75 37.00
S 0 62.00 2442.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
44 240.25 17169.25 0.00
Other 0 162.00 6510.96 0.00
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Total 460 3263.00 150250.46 59594.00
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 38.75 1433.75 0.00
U 0 0.00 0.00 0.00
B 3 1518.25 60430.25 0.00
P 120 1317.25 65315.00 65301.50
D 0 75.00 3049.75 37.00
S 5 69.00 2701.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
29 293.75 20918.50 0.00
Other 1 162.50 6529.46 0.00
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Total 159 3474.50 160377.71 65338.50
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 10 55.25 2044.25 0.00
U 0 0.00 0.00 0.00
B 25 1551.00 61642.00 0.00
P 21 1346.00 66378.75 66365.25
D 0 75.00 3049.75 37.00
S 0 69.00 2701.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
30 325.75 22875.00 0.00
Other 0 162.50 6529.46 0.00
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Total 86 3584.50 165220.21 66402.25