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: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 988 3272.00 121008.50 36.98
Subtotal (Total Children Is Unduplicated) 988 3272.00 121008.50 36.98
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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) 5 5.00 44.15 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 32.40 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.00 87.16 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 11.50 862.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.50 337.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 7.00 525.00 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 10 14.00 777.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 236 308.50 23137.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 86 137.50 10312.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 108 129.50 9686.00 74.80
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 288 426.00 23643.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 162 221.50 16612.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.00 1295.00 185.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.00 72.78 72.78
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
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) 547 1343.00 90763.29 67.58
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.00 350.00 50.00
Subtotal (Total Children Is Unduplicated) 2 7.00 350.00 50.00
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Total 4622.00 212121.79 45.89
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Number of Children (Unduplicated) With at Least One Service 1010
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 19 22.75 1424.25 0.00
U 0 0.00 0.00 0.00
B 200 170.25 6582.25 0.00
P 113 98.50 3879.75 3879.75
D 20 22.00 1611.00 0.00
S 194 179.00 6623.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
35 32.00 1276.50 0.00
Other 6 8.00 600.00 0.00
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Total 587 532.50 21996.75 3879.75
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 22.75 1424.25 0.00
U 0 0.00 0.00 0.00
B 113 280.75 10643.00 0.00
P 0 98.50 3879.75 3879.75
D 0 22.00 1611.00 0.00
S 1 180.25 6669.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
18 62.50 3369.00 0.00
Other 0 8.00 600.00 0.00
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Total 132 674.75 28196.25 3879.75
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 22.75 1424.25 0.00
U 0 0.00 0.00 0.00
B 7 285.25 10809.50 0.00
P 277 338.50 14125.00 14125.00
D 0 22.00 1611.00 0.00
S 0 180.25 6669.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
40 96.50 4627.00 0.00
Other 10 18.00 738.59 0.00
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Total 334 963.25 40004.59 14125.00
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 27.50 1600.00 0.00
U 0 0.00 0.00 0.00
B 161 462.75 19355.50 0.00
P 118 536.25 22033.75 21496.27
D 0 22.00 1611.00 0.00
S 0 180.25 6669.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
5 100.50 5219.00 0.00
Other 0 18.00 738.59 0.00
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Total 288 1347.25 57227.09 21496.27
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.50 1600.00 0.00
U 0 0.00 0.00 0.00
B 123 543.75 22401.28 0.00
P 0 536.25 22033.75 21496.27
D 0 22.00 1611.00 0.00
S 0 180.25 6669.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
8 111.00 5851.50 0.00
Other 0 18.00 738.59 0.00
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Total 131 1438.75 60905.37 21496.27
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.50 1600.00 0.00
U 0 0.00 0.00 0.00
B 99 619.25 25194.78 0.00
P 85 600.75 25180.25 24642.77
D 0 22.00 1611.00 0.00
S 0 180.25 6669.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
87 178.75 9066.67 0.00
Other 0 18.00 738.59 0.00
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Total 271 1646.50 70060.54 24642.77
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.50 1600.00 0.00
U 0 0.00 0.00 0.00
B 42 651.50 26438.03 0.00
P 181 793.00 34146.50 33609.02
D 0 22.00 1611.00 0.00
S 0 180.25 6669.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
18 209.75 11074.17 0.00
Other 0 18.00 738.59 0.00
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Total 241 1902.00 82277.54 33609.02
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.50 1600.00 0.00
U 0 0.00 0.00 0.00
B 74 739.75 30988.28 0.00
P 318 1176.50 54131.25 53493.77
D 0 22.00 1611.00 0.00
S 0 180.25 6669.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
12 228.25 12461.67 0.00
Other 0 18.00 738.59 0.00
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Total 404 2392.25 108200.04 53493.77
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 27.75 1609.25 0.00
U 0 0.00 0.00 0.00
B 500 1201.50 51001.03 0.00
P 169 1416.00 68747.50 68110.02
D 0 22.00 1611.00 0.00
S 66 246.50 9120.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 228.25 12461.67 0.00
Other 0 18.00 738.59 0.00
-------------------------------------------------
Total 736 3160.00 145289.54 68110.02
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.75 1609.25 0.00
U 0 0.00 0.00 0.00
B 194 1373.25 57754.78 0.00
P 0 1416.00 68747.50 68110.02
D 0 22.00 1611.00 0.00
S 0 246.50 9120.50 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
28 261.75 14797.67 0.00
Other 0 18.00 738.59 0.00
-------------------------------------------------
Total 222 3365.25 154379.29 68110.02
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.75 1609.25 0.00
U 0 0.00 0.00 0.00
B 303 1632.00 69233.03 0.00
P 0 1416.00 68747.50 68110.02
D 0 22.00 1611.00 0.00
S 1 247.50 9176.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
11 272.75 15469.67 0.00
Other 0 18.00 738.59 0.00
-------------------------------------------------
Total 315 3636.00 166585.04 68110.02
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.75 1609.25 0.00
U 0 0.00 0.00 0.00
B 1 1633.00 69270.03 0.00
P 152 1612.50 78947.50 78310.02
D 0 22.00 1611.00 0.00
S 0 247.50 9176.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 272.75 15469.67 0.00
Other 0 18.00 738.59 0.00
-------------------------------------------------
Total 153 3833.50 176822.04 78310.02
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.75 1609.25 0.00
U 0 0.00 0.00 0.00
B 5 1638.75 69691.78 0.00
P 424 1958.50 93089.50 92452.02
D 0 22.00 1611.00 0.00
S 0 247.50 9176.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
15 290.50 16714.42 0.00
Other 1 19.50 821.84 0.00
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Total 445 4204.50 192713.79 92452.02
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 27.75 1609.25 0.00
U 0 0.00 0.00 0.00
B 0 1638.75 69691.78 0.00
P 161 2130.00 99815.50 99178.02
D 0 22.00 1611.00 0.00
S 0 247.50 9176.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
40 364.50 21594.67 0.00
Other 0 19.50 821.84 0.00
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Total 201 4450.00 204320.04 99178.02
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 33.50 1822.00 0.00
U 0 0.00 0.00 0.00
B 30 1681.75 71803.03 0.00
P 95 2247.75 104939.25 104301.77
D 0 22.00 1611.00 0.00
S 0 247.50 9176.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
4 370.00 21948.67 0.00
Other 0 19.50 821.84 0.00
-------------------------------------------------
Total 132 4622.00 212121.79 104301.77