CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 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 333 925.25 34178.75 36.94
Subtotal (Total Children Is Unduplicated) 333 925.25 34178.75 36.94
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.00 17.66 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.50 112.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.00 225.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 4.00 300.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.00 277.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 23.00 1725.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 6.50 487.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 15.50 1162.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 17.00 943.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 20.00 1500.00 75.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.00 436.68 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 10 10.00 501.50 50.15
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 16 16.00 800.00 50.00
Subtotal (Total Children Is Unduplicated) 63 138.00 8821.29 63.92
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 110.00 5500.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 7 13.25 899.41 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 16.00 1086.08 67.88
Subtotal (Total Children Is Unduplicated) 29 139.25 7485.49 53.76
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Total 1202.50 50485.53 41.98
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Number of Children (Unduplicated) With at Least One Service 335
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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 310 226.75 9201.50 0.00
P 50 46.25 1711.25 1711.25
D 12 8.00 523.50 0.00
S 68 59.50 2201.50 0.00
H 7 6.50 487.50 0.00
T 0 0.00 0.00 0.00
45 74.25 3576.05 0.00
Other 15 15.50 1087.50 0.00
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Total 507 436.75 18788.80 1711.25
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 90 289.00 11617.75 0.00
P 124 149.00 5513.00 5513.00
D 0 8.00 523.50 0.00
S 0 59.50 2201.50 0.00
H 7 29.50 1653.88 1166.38
T 0 0.00 0.00 0.00
0 74.25 3576.05 0.00
Other 0 15.50 1087.50 0.00
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Total 221 624.75 26173.18 6679.38
Center 05
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 253 423.00 16601.90 0.00
P 8 155.25 5783.25 5783.25
D 0 8.00 523.50 0.00
S 0 59.50 2201.50 0.00
H 0 29.50 1653.88 1166.38
T 0 0.00 0.00 0.00
27 101.25 5064.08 0.00
Other 0 15.50 1087.50 0.00
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Total 288 792.00 32915.61 6949.63
Center 06
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 291 600.00 23150.90 0.00
P 0 155.25 5783.25 5783.25
D 0 8.00 523.50 0.00
S 0 59.50 2201.50 0.00
H 0 29.50 1653.88 1166.38
T 0 0.00 0.00 0.00
67 160.25 8504.51 0.00
Other 0 15.50 1087.50 0.00
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Total 358 1028.00 42905.04 6949.63
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 14 610.75 23661.65 0.00
P 23 182.50 7017.50 7017.50
D 0 8.00 523.50 0.00
S 19 69.00 2553.00 0.00
H 0 29.50 1653.88 1166.38
T 0 0.00 0.00 0.00
4 167.75 8888.45 0.00
Other 0 15.50 1087.50 0.00
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Total 60 1083.00 45385.48 8183.88
Center 51
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 56 664.25 25641.15 0.00
P 0 182.50 7017.50 7017.50
D 0 8.00 523.50 0.00
S 0 69.00 2553.00 0.00
H 0 29.50 1653.88 1166.38
T 0 0.00 0.00 0.00
4 173.75 9240.59 0.00
Other 0 15.50 1087.50 0.00
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Total 60 1142.50 47717.12 8183.88
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 6 668.75 25826.15 0.00
P 0 182.50 7017.50 7017.50
D 0 8.00 523.50 0.00
S 4 73.25 2710.25 0.00
H 0 29.50 1653.88 1166.38
T 0 0.00 0.00 0.00
0 173.75 9240.59 0.00
Other 0 15.50 1087.50 0.00
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Total 11 1152.25 48134.37 8183.88
Center 53
Flag Claims Units Chgs Paid
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R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 14 680.50 26299.90 0.00
P 20 199.00 7921.75 7921.75
D 0 8.00 523.50 0.00
S 0 73.25 2710.25 0.00
H 0 29.50 1653.88 1166.38
T 0 0.00 0.00 0.00
0 173.75 9240.59 0.00
Other 0 15.50 1087.50 0.00
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Total 34 1180.50 49512.37 9088.13
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 1.00 75.00 0.00
U 0 0.00 0.00 0.00
B 0 680.50 26299.90 0.00
P 39 218.75 8756.50 8756.50
D 0 8.00 523.50 0.00
S 1 74.25 2760.25 0.00
H 0 29.50 1653.88 1166.38
T 0 0.00 0.00 0.00
2 175.00 9329.00 0.00
Other 0 15.50 1087.50 0.00
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Total 42 1202.50 50485.53 9922.88