CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 337 788.25 29091.25 36.91
Subtotal (Total Children Is Unduplicated) 337 788.25 29091.25 36.91
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.00 111.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.50 712.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.50 337.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.50 112.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 12.00 666.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 9.00 675.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 550.00 275.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 9.00 450.00 50.00
Subtotal (Total Children Is Unduplicated) 28 59.50 4294.46 72.18
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 122.00 6100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 10.50 712.74 67.88
PHY-97110-PT SESSION BY LICENSED PT 7 37.25 2528.53 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 13.00 882.44 67.88
Subtotal (Total Children Is Unduplicated) 29 183.75 10273.71 55.91
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Total 1031.50 43659.42 42.33
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Number of Children (Unduplicated) With at Least One Service 339
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Center 01
Flag Claims Units Chgs Paid
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R 12 7.00 259.00 0.00
U 0 0.00 0.00 0.00
B 250 211.25 7742.25 0.00
P 1 1.00 50.00 50.00
D 10 9.25 513.25 0.00
S 111 70.75 2617.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
23 62.25 3406.01 50.00
Other 9 19.50 1234.66 0.00
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Total 416 381.00 15822.92 100.00
Center 04
Flag Claims Units Chgs Paid
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R 23 27.25 1008.25 0.00
U 0 0.00 0.00 0.00
B 124 286.50 10658.00 0.00
P 90 54.25 2020.25 2020.25
D 0 9.25 513.25 0.00
S 0 70.75 2617.75 0.00
H 9 33.00 1793.04 1793.04
T 0 0.00 0.00 0.00
14 75.25 4511.01 50.00
Other 0 19.50 1234.66 0.00
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Total 260 575.75 24356.21 3863.29
Center 05
Flag Claims Units Chgs Paid
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R 0 27.25 1008.25 0.00
U 0 0.00 0.00 0.00
B 199 397.25 14768.90 0.00
P 1 55.25 2070.25 2070.25
D 0 9.25 513.25 0.00
S 0 70.75 2617.75 0.00
H 0 33.00 1793.04 1793.04
T 0 0.00 0.00 0.00
14 89.25 5257.32 50.00
Other 0 19.50 1234.66 0.00
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Total 214 701.50 29263.42 3913.29
Center 06
Flag Claims Units Chgs Paid
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R 1 27.75 1026.75 0.00
U 0 0.00 0.00 0.00
B 15 406.75 15120.40 0.00
P 248 190.25 7065.25 7065.25
D 0 9.25 513.25 0.00
S 0 70.75 2617.75 0.00
H 0 33.00 1793.04 1793.04
T 0 0.00 0.00 0.00
36 118.00 7070.38 50.00
Other 0 19.50 1234.66 0.00
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Total 300 875.25 36441.48 8908.29
Center 10
Flag Claims Units Chgs Paid
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R 3 29.75 1100.75 0.00
U 0 0.00 0.00 0.00
B 8 411.75 15305.40 0.00
P 3 191.00 7093.00 7093.00
D 0 9.25 513.25 0.00
S 3 71.75 2654.75 0.00
H 0 33.00 1793.04 1793.04
T 0 0.00 0.00 0.00
8 134.00 8156.46 50.00
Other 0 19.50 1234.66 0.00
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Total 25 900.00 37851.31 8936.04
Center 51
Flag Claims Units Chgs Paid
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R 0 29.75 1100.75 0.00
U 0 0.00 0.00 0.00
B 32 433.50 16121.65 0.00
P 0 191.00 7093.00 7093.00
D 0 9.25 513.25 0.00
S 0 71.75 2654.75 0.00
H 0 33.00 1793.04 1793.04
T 0 0.00 0.00 0.00
2 135.75 8257.37 50.00
Other 0 19.50 1234.66 0.00
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Total 34 923.50 38768.47 8936.04
Center 52
Flag Claims Units Chgs Paid
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R 0 29.75 1100.75 0.00
U 0 0.00 0.00 0.00
B 6 438.50 16306.65 0.00
P 8 195.50 7259.50 7259.50
D 0 9.25 513.25 0.00
S 0 71.75 2654.75 0.00
H 0 33.00 1793.04 1793.04
T 0 0.00 0.00 0.00
3 139.75 8503.12 50.00
Other 0 19.50 1234.66 0.00
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Total 17 937.00 39365.72 9102.54
Center 53
Flag Claims Units Chgs Paid
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R 19 46.75 1818.75 0.00
U 0 0.00 0.00 0.00
B 12 451.25 16778.40 0.00
P 15 209.50 8007.50 8007.50
D 0 9.25 513.25 0.00
S 0 71.75 2654.75 0.00
H 0 33.00 1793.04 1793.04
T 0 0.00 0.00 0.00
18 158.25 9408.62 50.00
Other 0 19.50 1234.66 0.00
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Total 64 999.25 42208.97 9850.54
Center 54
Flag Claims Units Chgs Paid
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R 0 46.75 1818.75 0.00
U 0 0.00 0.00 0.00
B 19 464.75 17394.90 0.00
P 20 222.75 8510.75 8510.75
D 0 9.25 513.25 0.00
S 0 71.75 2654.75 0.00
H 0 33.00 1793.04 1793.04
T 0 0.00 0.00 0.00
5 163.75 9739.32 50.00
Other 0 19.50 1234.66 0.00
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Total 44 1031.50 43659.42 10353.79