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: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 995 3499.75 129389.00 36.97
Subtotal (Total Children Is Unduplicated) 995 3499.75 129389.00 36.97
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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) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 13.00 975.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.00 675.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 10.00 750.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 7.50 562.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 29.00 1609.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 254 313.00 23369.00 74.66
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 100 144.00 10800.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 110 140.00 10473.50 74.81
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 306 437.50 24281.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 160 215.00 16125.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 22.00 3347.50 152.16
SCREEN-T1023-INTERDISCIPLINARY SCREENING 27 30.00 1500.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 2 2.00 97.00 48.50
Subtotal (Total Children Is Unduplicated) 561 1377.00 94637.29 68.73
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.00 25.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.00 400.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.00 271.52 67.88
Subtotal (Total Children Is Unduplicated) 3 13.00 696.52 53.58
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Total 4889.75 224722.81 45.96
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Number of Children (Unduplicated) With at Least One Service 1029
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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 360 296.25 12123.75 0.00
P 53 35.75 1332.00 1332.00
D 11 11.50 605.25 0.00
S 100 90.50 3348.50 0.00
H 6 6.00 450.00 0.00
T 0 0.00 0.00 0.00
23 24.00 832.50 0.00
Other 10 12.50 908.25 0.00
-------------------------------------------------
Total 563 476.50 19600.25 1332.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 2.25 83.25 0.00
U 0 0.00 0.00 0.00
B 83 378.50 15139.25 0.00
P 0 35.75 1332.00 1332.00
D 0 11.50 605.25 0.00
S 0 90.50 3348.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
21 66.75 3378.75 0.00
Other 0 12.50 908.25 0.00
-------------------------------------------------
Total 106 603.75 25245.25 1332.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 2.25 83.25 0.00
U 0 0.00 0.00 0.00
B 16 399.25 16265.50 0.00
P 259 278.00 11293.50 11210.25
D 0 11.50 605.25 0.00
S 0 90.50 3348.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
16 89.25 4211.25 0.00
Other 5 17.50 980.29 0.00
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Total 296 894.25 37237.54 11210.25
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 2.25 83.25 0.00
U 0 0.00 0.00 0.00
B 193 638.75 27424.00 0.00
P 183 533.25 21329.75 20755.29
D 0 11.50 605.25 0.00
S 0 90.50 3348.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
14 103.25 6653.25 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 390 1403.00 60874.29 20755.29
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 2.25 83.25 0.00
U 0 0.00 0.00 0.00
B 70 698.25 29625.50 0.00
P 0 533.25 21329.75 20755.29
D 0 11.50 605.25 0.00
S 0 90.50 3348.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
18 124.25 7808.25 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 88 1483.50 64230.79 20755.29
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 2.25 83.25 0.00
U 0 0.00 0.00 0.00
B 214 871.50 36035.75 0.00
P 0 533.25 21329.75 20755.29
D 0 11.50 605.25 0.00
S 0 90.50 3348.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
33 166.75 10822.75 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 247 1699.25 73655.54 20755.29
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 2.25 83.25 0.00
U 0 0.00 0.00 0.00
B 111 971.75 40226.00 0.00
P 100 625.00 25451.25 24876.79
D 0 11.50 605.25 0.00
S 0 90.50 3348.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
15 193.75 12565.00 0.00
Other 0 17.50 980.29 0.00
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Total 226 1918.25 83709.54 24876.79
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 6.25 268.25 0.00
U 0 0.00 0.00 0.00
B 86 1080.75 46172.75 0.00
P 292 928.50 41726.50 41152.03
D 0 11.50 605.25 0.00
S 0 90.50 3348.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
7 202.50 13076.25 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 387 2343.50 106627.79 41152.03
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 13 21.00 879.75 0.00
U 0 0.00 0.00 0.00
B 380 1425.00 59319.50 0.00
P 701 1693.75 82153.75 81579.28
D 0 11.50 605.25 0.00
S 47 131.50 4865.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
1 203.00 13094.75 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 1142 3509.25 162348.79 81579.28
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 23.00 1029.75 0.00
U 0 0.00 0.00 0.00
B 330 1707.25 70217.25 0.00
P 0 1693.75 82153.75 81579.28
D 0 11.50 605.25 0.00
S 0 131.50 4865.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
27 235.00 15439.77 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 359 3825.50 175741.56 81579.28
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 2 26.50 1292.25 0.00
U 0 0.00 0.00 0.00
B 186 1870.50 77794.25 0.00
P 0 1693.75 82153.75 81579.28
D 0 11.50 605.25 0.00
S 0 131.50 4865.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
7 242.00 15782.27 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 195 3999.25 183923.56 81579.28
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 26.50 1292.25 0.00
U 0 0.00 0.00 0.00
B 31 1905.50 79089.25 0.00
P 51 1771.75 86240.50 85666.03
D 0 11.50 605.25 0.00
S 0 131.50 4865.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
4 250.00 16382.27 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 86 4120.25 189905.31 85666.03
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 26.50 1292.25 0.00
U 0 0.00 0.00 0.00
B 7 1912.75 79357.50 0.00
P 441 2134.50 101542.00 100967.53
D 0 11.50 605.25 0.00
S 0 131.50 4865.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
23 274.25 18055.02 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 471 4514.50 207147.81 100967.53
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 26.50 1292.25 0.00
U 0 0.00 0.00 0.00
B 0 1912.75 79357.50 0.00
P 158 2306.00 108457.50 107783.03
D 0 11.50 605.25 0.00
S 2 134.50 4976.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
52 356.75 23260.52 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 212 4771.50 219379.81 107783.03
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 26.50 1292.25 0.00
U 0 0.00 0.00 0.00
B 21 1944.25 80607.75 0.00
P 49 2375.25 111423.00 110748.53
D 0 11.50 605.25 0.00
S 0 134.50 4976.50 0.00
H 0 6.00 450.00 0.00
T 0 0.00 0.00 0.00
14 374.25 24387.77 0.00
Other 0 17.50 980.29 0.00
-------------------------------------------------
Total 84 4889.75 224722.81 110748.53