CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 319 692.25 25613.25 37.00
Subtotal (Total Children Is Unduplicated) 319 692.25 25613.25 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 2.00 21.60 10.80
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.00 8.44 8.44
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 2.00 43.58 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.50 262.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 3.50 262.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.50 412.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 6.00 333.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 17.00 1275.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 12.50 937.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.50 525.00 70.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 10.50 582.75 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 33.50 2512.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 5 5.00 250.75 50.15
SCREEN-T1023-INTERDISCIPLINARY SCREENING 7 7.00 350.00 50.00
Subtotal (Total Children Is Unduplicated) 60 126.50 8732.57 69.03
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 42.00 2100.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 3 4.00 271.52 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 18.50 1255.78 67.88
Subtotal (Total Children Is Unduplicated) 18 64.50 3627.30 56.24
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Total 883.25 37973.12 42.99
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Number of Children (Unduplicated) With at Least One Service 324
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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 181 123.00 4720.00 0.00
P 15 12.50 462.50 462.50
D 0 0.00 0.00 0.00
S 40 27.75 1026.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8 10.00 535.88 0.00
Other 40 41.75 2652.50 0.00
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Total 284 215.00 9397.63 462.50
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 175 235.50 9100.75 0.00
P 45 42.75 1610.00 1610.00
D 0 0.00 0.00 0.00
S 0 27.75 1026.75 0.00
H 1 3.00 150.00 150.00
T 0 0.00 0.00 0.00
6 15.50 1171.38 0.00
Other 0 41.75 2652.50 0.00
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Total 227 366.25 15711.38 1760.00
Center 05
Flag Claims Units Chgs Paid
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R 16 7.25 268.25 0.00
U 0 0.00 0.00 0.00
B 272 384.25 15007.44 0.00
P 0 42.75 1610.00 1610.00
D 0 0.00 0.00 0.00
S 0 27.75 1026.75 0.00
H 0 3.00 150.00 150.00
T 0 0.00 0.00 0.00
6 21.50 1594.31 0.00
Other 0 41.75 2652.50 0.00
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Total 294 528.25 22309.25 1760.00
Center 06
Flag Claims Units Chgs Paid
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R 0 7.25 268.25 0.00
U 0 0.00 0.00 0.00
B 137 482.50 18642.69 0.00
P 65 81.00 3025.25 3025.25
D 0 0.00 0.00 0.00
S 0 27.75 1026.75 0.00
H 0 3.00 150.00 150.00
T 0 0.00 0.00 0.00
70 78.75 5078.56 0.00
Other 0 41.75 2652.50 0.00
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Total 272 722.00 30844.00 3175.25
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.25 268.25 0.00
U 0 0.00 0.00 0.00
B 1 482.75 18651.94 0.00
P 0 81.00 3025.25 3025.25
D 0 0.00 0.00 0.00
S 0 27.75 1026.75 0.00
H 0 3.00 150.00 150.00
T 0 0.00 0.00 0.00
0 78.75 5078.56 0.00
Other 0 41.75 2652.50 0.00
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Total 1 722.25 30853.25 3175.25
Center 10
Flag Claims Units Chgs Paid
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R 0 7.25 268.25 0.00
U 0 0.00 0.00 0.00
B 20 499.25 19299.44 0.00
P 6 88.75 3540.00 3540.00
D 0 0.00 0.00 0.00
S 0 27.75 1026.75 0.00
H 0 3.00 150.00 150.00
T 0 0.00 0.00 0.00
0 78.75 5078.56 0.00
Other 0 41.75 2652.50 0.00
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Total 26 746.50 32015.50 3690.00
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.25 268.25 0.00
U 0 0.00 0.00 0.00
B 47 539.25 20931.44 0.00
P 0 88.75 3540.00 3540.00
D 0 0.00 0.00 0.00
S 0 27.75 1026.75 0.00
H 0 3.00 150.00 150.00
T 0 0.00 0.00 0.00
8 90.75 5889.48 0.00
Other 0 41.75 2652.50 0.00
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Total 55 798.50 34458.42 3690.00
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.25 268.25 0.00
U 0 0.00 0.00 0.00
B 15 548.50 21273.69 0.00
P 0 88.75 3540.00 3540.00
D 0 0.00 0.00 0.00
S 0 27.75 1026.75 0.00
H 0 3.00 150.00 150.00
T 0 0.00 0.00 0.00
0 90.75 5889.48 0.00
Other 0 41.75 2652.50 0.00
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Total 15 807.75 34800.67 3690.00
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.25 268.25 0.00
U 0 0.00 0.00 0.00
B 0 548.50 21273.69 0.00
P 22 113.50 4746.75 4746.75
D 0 0.00 0.00 0.00
S 0 27.75 1026.75 0.00
H 0 3.00 150.00 150.00
T 0 0.00 0.00 0.00
6 96.75 5971.93 0.00
Other 0 41.75 2652.50 0.00
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Total 28 838.50 36089.87 4896.75
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.25 268.25 0.00
U 0 0.00 0.00 0.00
B 22 565.75 22101.44 0.00
P 48 141.00 5802.25 5802.25
D 0 0.00 0.00 0.00
S 0 27.75 1026.75 0.00
H 0 3.00 150.00 150.00
T 0 0.00 0.00 0.00
0 96.75 5971.93 0.00
Other 0 41.75 2652.50 0.00
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Total 70 883.25 37973.12 5952.25