CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 299 773.50 28619.50 37.00
Subtotal (Total Children Is Unduplicated) 299 773.50 28619.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 10.50 787.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 10.00 750.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.00 150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 21.00 1165.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 22.50 1687.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.00 925.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 5 5.00 363.90 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 100.30 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 10 11.00 550.00 50.00
Subtotal (Total Children Is Unduplicated) 56 100.00 7155.97 71.56
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 103.00 5150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 7.50 509.10 67.88
PHY-97110-PT SESSION BY LICENSED PT 3 14.00 950.32 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.00 339.40 67.88
Subtotal (Total Children Is Unduplicated) 22 129.50 6948.82 53.66
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Total 1003.00 42724.29 42.60
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Number of Children (Unduplicated) With at Least One Service 304
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Center 01
Flag Claims Units Chgs Paid
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R 20 18.00 1149.50 0.00
U 0 0.00 0.00 0.00
B 212 147.50 5971.25 0.00
P 136 94.25 3699.50 3699.50
D 3 3.00 225.00 0.00
S 78 58.75 2173.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
18 37.25 1805.75 0.00
Other 1 2.00 100.00 0.00
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Total 468 360.75 15124.75 3699.50
Center 04
Flag Claims Units Chgs Paid
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R 1 18.75 1177.25 0.00
U 0 0.00 0.00 0.00
B 77 213.25 8459.50 0.00
P 118 176.75 7048.00 6779.26
D 0 3.00 225.00 0.00
S 0 58.75 2173.75 0.00
H 8 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
6 41.50 2407.00 0.00
Other 0 2.00 100.00 0.00
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Total 210 538.00 22808.38 7997.14
Center 05
Flag Claims Units Chgs Paid
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R 1 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 254 367.50 14414.02 0.00
P 0 176.75 7048.00 6779.26
D 0 3.00 225.00 0.00
S 0 58.75 2173.75 0.00
H 0 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
5 46.00 2625.65 0.00
Other 0 2.00 100.00 0.00
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Total 260 697.75 29054.33 7997.14
Center 06
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 100 441.75 17161.27 37.00
P 79 237.00 9391.25 9122.51
D 0 3.00 225.00 0.00
S 0 58.75 2173.75 0.00
H 0 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
60 105.25 6079.85 0.00
Other 0 2.00 100.00 0.00
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Total 239 891.50 37599.03 10377.39
Center 07
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 0 441.75 17161.27 37.00
P 6 243.00 9613.25 9344.51
D 0 3.00 225.00 0.00
S 0 58.75 2173.75 0.00
H 0 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
0 105.25 6079.85 0.00
Other 0 2.00 100.00 0.00
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Total 6 897.50 37821.03 10599.39
Center 10
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 10 449.00 17466.52 37.00
P 4 246.50 9856.75 9588.01
D 0 3.00 225.00 0.00
S 6 61.50 2275.50 0.00
H 0 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
0 105.25 6079.85 0.00
Other 0 2.00 100.00 0.00
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Total 20 911.00 38471.53 10842.89
Center 51
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 31 468.75 18197.27 37.00
P 0 246.50 9856.75 9588.01
D 0 3.00 225.00 0.00
S 0 61.50 2275.50 0.00
H 0 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
11 125.75 7364.11 0.00
Other 0 2.00 100.00 0.00
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Total 42 951.25 40486.54 10842.89
Center 52
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 18 483.50 18874.52 37.00
P 0 246.50 9856.75 9588.01
D 0 3.00 225.00 0.00
S 0 61.50 2275.50 0.00
H 0 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
1 126.75 7414.11 0.00
Other 0 2.00 100.00 0.00
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Total 19 967.00 41213.79 10842.89
Center 53
Flag Claims Units Chgs Paid
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R 0 19.75 1250.03 0.00
U 0 0.00 0.00 0.00
B 0 483.50 18874.52 37.00
P 16 258.50 10378.75 10110.01
D 3 4.50 280.50 0.00
S 0 61.50 2275.50 0.00
H 0 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
0 126.75 7414.11 0.00
Other 0 2.00 100.00 0.00
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Total 19 980.50 41791.29 11364.89
Center 54
Flag Claims Units Chgs Paid
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R 1 20.25 1268.53 0.00
U 0 0.00 0.00 0.00
B 1 485.50 19024.52 37.00
P 32 277.25 11085.50 10816.76
D 0 4.50 280.50 0.00
S 0 61.50 2275.50 0.00
H 0 24.00 1217.88 1217.88
T 0 0.00 0.00 0.00
2 128.00 7471.86 0.00
Other 0 2.00 100.00 0.00
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Total 36 1003.00 42724.29 12071.64