CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:TPIN
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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.00 74.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 9.50 351.50 37.00
Subtotal (Total Children Is Unduplicated) 3 11.50 425.50 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.00 61.81 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.00 54.00 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.00 152.53 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 9.50 686.00 72.21
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.00 375.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.00 198.50 66.17
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 4 6.50 360.75 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 150 212.66 15949.49 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 58 84.10 6307.42 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 48 58.50 4334.50 74.09
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 90 148.58 8246.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 87.00 7421.89 85.31
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 241 638.84 44428.91 69.55
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 4.00 271.52 67.88
Subtotal (Total Children Is Unduplicated) 1 4.00 271.52 67.88
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Total 654.34 45125.93 68.96
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Number of Children (Unduplicated) With at Least One Service 245
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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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 26 28.50 1952.25 0.00
S 8 10.25 379.25 0.00
H 9 10.00 652.50 0.00
T 0 0.00 0.00 0.00
2 2.25 121.25 0.00
Other 11 15.50 1084.50 0.00
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Total 56 66.50 4189.75 0.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 0 10.00 652.50 0.00
T 0 0.00 0.00 0.00
0 2.25 121.25 0.00
Other 10 25.50 1228.58 0.00
-------------------------------------------------
Total 10 76.50 4333.83 0.00
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 0 10.00 652.50 0.00
T 0 0.00 0.00 0.00
2 4.25 271.25 0.00
Other 0 25.50 1228.58 0.00
-------------------------------------------------
Total 2 78.50 4483.83 0.00
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 0 10.00 652.50 0.00
T 0 0.00 0.00 0.00
63 82.75 5561.80 0.00
Other 0 25.50 1228.58 0.00
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Total 63 157.00 9774.38 0.00
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 0 10.00 652.50 0.00
T 0 0.00 0.00 0.00
2 85.75 5786.80 0.00
Other 0 25.50 1228.58 0.00
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Total 2 160.00 9999.38 0.00
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 1 1.00 75.00 80.00
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 0 10.00 652.50 0.00
T 0 0.00 0.00 0.00
66 155.25 10882.30 0.00
Other 0 25.50 1228.58 0.00
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Total 67 230.50 15169.88 80.00
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 1.00 75.00 80.00
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 0 10.00 652.50 0.00
T 0 0.00 0.00 0.00
170 442.75 30368.05 0.00
Other 0 25.50 1228.58 0.00
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Total 170 518.00 34655.63 80.00
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 1.00 75.00 80.00
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 0 10.00 652.50 0.00
T 0 0.00 0.00 0.00
1 444.25 30480.55 0.00
Other 0 25.50 1228.58 0.00
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Total 1 519.50 34768.13 80.00
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 1.00 75.00 80.00
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 9 22.50 1570.50 0.00
T 0 0.00 0.00 0.00
32 487.75 33294.55 0.00
Other 0 25.50 1228.58 0.00
-------------------------------------------------
Total 41 575.50 38500.13 80.00
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 3 3.68 255.00 260.00
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 0 22.50 1570.50 0.00
T 0 0.00 0.00 0.00
2 491.75 33555.55 0.00
Other 0 25.50 1228.58 0.00
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Total 5 582.18 38941.13 260.00
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 3 7.18 1239.39 791.09
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 0 22.50 1570.50 0.00
T 0 0.00 0.00 0.00
25 522.75 35861.05 0.00
Other 0 25.50 1228.58 0.00
-------------------------------------------------
Total 28 616.68 42231.02 791.09
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 2 10.18 1639.39 1191.09
D 0 28.50 1952.25 0.00
S 0 10.25 379.25 0.00
H 0 22.50 1570.50 0.00
T 0 0.00 0.00 0.00
21 557.41 38355.96 0.00
Other 0 25.50 1228.58 0.00
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Total 23 654.34 45125.93 1191.09