CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Payclass Filters:OTHER
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 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 47.50 1757.50 37.00
Subtotal (Total Children Is Unduplicated) 14 48.50 1794.50 37.00
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 16.00 1200.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 12.00 900.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.00 675.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 9 9.00 1665.00 185.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 3 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 39 57.00 5112.00 89.68
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Total 105.50 6906.50 65.46
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Number of Children (Unduplicated) With at Least One Service 53
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Center 04
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 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
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
9 9.00 1665.00 0.00
Other 0 0.00 0.00 0.00
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Total 9 9.00 1665.00 0.00
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 0 0.00 0.00 0.00
P 1 1.00 75.00 75.00
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 9.00 1665.00 0.00
Other 0 0.00 0.00 0.00
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Total 1 10.00 1740.00 75.00
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 0 0.00 0.00 0.00
P 0 1.00 75.00 75.00
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
10 16.00 1924.00 0.00
Other 0 0.00 0.00 0.00
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Total 10 17.00 1999.00 75.00
Center 07
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 0 0.00 0.00 0.00
P 0 1.00 75.00 75.00
D 0 0.00 0.00 0.00
S 2 4.00 261.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 17.25 1970.25 0.00
Other 0 0.00 0.00 0.00
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Total 4 22.25 2306.25 75.00
Center 09
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 0 0.00 0.00 0.00
P 0 1.00 75.00 75.00
D 0 0.00 0.00 0.00
S 0 4.00 261.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
23 49.75 4313.25 0.00
Other 0 0.00 0.00 0.00
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Total 23 54.75 4649.25 75.00
Center 52
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 0 0.00 0.00 0.00
P 0 1.00 75.00 75.00
D 0 0.00 0.00 0.00
S 0 4.00 261.00 0.00
H 7 10.50 768.00 0.00
T 0 0.00 0.00 0.00
0 49.75 4313.25 0.00
Other 0 0.00 0.00 0.00
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Total 7 65.25 5417.25 75.00
Center 53
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 16 15.25 564.25 0.00
P 0 1.00 75.00 75.00
D 0 0.00 0.00 0.00
S 0 4.00 261.00 0.00
H 0 10.50 768.00 0.00
T 0 0.00 0.00 0.00
28 74.75 5238.25 0.00
Other 0 0.00 0.00 0.00
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Total 44 105.50 6906.50 75.00