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
Bill Flag Filter:RBPU
Eligibility Filter:All
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 10395 32520.5 1202217.00 36.97
Subtotal (Total Children Is Unduplicated) 10395 32520.5 1202217.00 36.97
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.00 125.00 125.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 72 98.00 7350.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 31.50 2362.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 35 42.50 3187.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 44 69.50 5212.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 74 99.50 5511.25 55.39
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 652 913.00 68400.00 74.92
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 242 399.00 29925.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 327 412.50 30937.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 952 1399.50 77672.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 609 963.00 72225.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 28 28.00 5035.50 179.84
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.00 945.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 2 2.00 100.30 50.15
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 105 105.00 5250.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 1854 4590.00 315686.76 68.78
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 11.00 275.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 311 1441.50 72075.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 36 194.75 13219.63 67.88
PHY-97110-PT SESSION BY LICENSED PT 28 122.75 8332.27 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 124.00 8417.12 67.88
Subtotal (Total Children Is Unduplicated) 388 1897.00 102469.02 54.02
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Total 39007.50 1620372.78 41.54
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Number of Children (Unduplicated) With at Least One Service 10641
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 109 123.25 7777.00 0.00
U 0 0.00 0.00 0.00
B 2448 1728.50 66954.25 0.00
P 1568 1143.00 43760.25 43759.75
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4125 2994.75 118491.50 43759.75
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 12 132.50 8119.25 0.00
U 0 0.00 0.00 0.00
B 1045 2594.00 98811.25 0.00
P 0 1143.00 43760.25 43759.75
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1057 3869.50 150690.75 43759.75
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 133.25 8147.00 0.00
U 0 0.00 0.00 0.00
B 77 2641.00 100604.00 0.00
P 2196 2793.75 110548.75 117682.75
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2276 5568.00 219299.75 117682.75
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 30 160.25 9146.00 0.00
U 0 0.00 0.00 0.00
B 2043 4699.75 186180.25 0.00
P 2550 5366.00 210879.84 213467.46
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4623 10226.00 406206.09 213467.46
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 161.25 9218.78 0.00
U 0 0.00 0.00 0.00
B 2378 5991.25 234363.95 0.00
P 3 5368.00 210953.84 213495.21
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2382 11520.50 454536.57 213495.21
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 161.25 9218.78 0.00
U 0 0.00 0.00 0.00
B 1633 7187.25 278615.95 619.75
P 1540 6558.25 263429.09 265932.96
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3173 13906.75 551263.82 266552.71
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 21 171.75 9740.28 0.00
U 0 0.00 0.00 0.00
B 1178 7916.75 306390.45 619.75
P 3496 9039.00 368466.87 370970.74
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4695 17127.50 684597.60 371590.49
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 179.50 10027.03 0.00
U 0 0.00 0.00 0.00
B 899 8750.00 345988.27 824.01
P 3205 11875.50 498785.14 501060.26
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4110 20805.00 854800.44 501884.27
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 19 188.75 10369.28 0.00
U 0 0.00 0.00 0.00
B 5947 12740.25 504075.02 824.01
P 1502 13249.25 572202.58 574443.76
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 7468 26178.25 1086646.88 575267.77
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 190.50 10434.03 0.00
U 0 0.00 0.00 0.00
B 3208 15030.25 590533.12 824.01
P 0 13249.25 572202.58 574443.76
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 3212 28470.00 1173169.73 575267.77
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 190.50 10434.03 0.00
U 0 0.00 0.00 0.00
B 2502 16805.50 669309.91 824.01
P 0 13249.25 572202.58 574443.76
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2502 30245.25 1251946.52 575267.77
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 191.25 10461.78 0.00
U 0 0.00 0.00 0.00
B 10 16814.75 669727.66 824.01
P 2187 15411.25 675657.83 677899.01
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2200 32417.25 1355847.27 678723.02
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 6 194.50 10582.03 0.00
U 0 0.00 0.00 0.00
B 100 16911.50 675087.67 824.01
P 3964 18166.75 785716.58 787948.51
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 4070 35272.75 1471386.28 788772.52
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 199.25 10757.78 0.00
U 0 0.00 0.00 0.00
B 0 16911.50 675087.67 824.01
P 1075 19237.00 827856.08 830088.01
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 1080 36347.75 1513701.53 830912.02
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 118 348.75 16458.78 0.00
U 0 0.00 0.00 0.00
B 466 17449.50 697448.92 824.01
P 1850 21209.25 906465.08 908697.01
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2434 39007.50 1620372.78 909521.02