CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/15/2010 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 883 3183.00 117623.00 36.95
Subtotal (Total Children Is Unduplicated) 883 3183.00 117623.00 36.95
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 10.00 750.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.00 525.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 8.50 637.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 8.50 637.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 15.50 860.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 214 277.50 20776.00 74.87
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 115 172.50 12937.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 107 138.00 10350.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 279 411.00 22756.00 55.37
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 159 218.50 16387.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 18 18.00 3330.00 185.00
SCREEN-T1023-INTERDISCIPLINARY SCREENING 14 14.00 700.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 500 1304.00 90823.37 69.65
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 5.25 262.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 1.50 101.82 67.88
Subtotal (Total Children Is Unduplicated) 2 6.75 364.32 53.97
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Total 4493.75 208810.69 46.47
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Number of Children (Unduplicated) With at Least One Service 922
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Center 01
Flag Claims Units Chgs Paid
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R 10 11.00 545.75 0.00
U 0 0.00 0.00 0.00
B 230 205.00 7838.75 0.00
P 1 2.50 92.50 0.00
D 19 32.50 2351.25 0.00
S 161 132.75 4911.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
14 13.00 557.00 0.00
Other 8 12.50 859.50 0.00
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Total 443 409.25 17156.50 0.00
Center 02
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 11.00 545.75 0.00
U 0 0.00 0.00 0.00
B 67 271.50 10243.75 0.00
P 0 2.50 92.50 0.00
D 0 32.50 2351.25 0.00
S 0 132.75 4911.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
17 42.00 2414.75 0.00
Other 0 12.50 859.50 0.00
-------------------------------------------------
Total 84 504.75 21419.25 0.00
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
R 4 16.00 730.75 0.00
U 0 0.00 0.00 0.00
B 9 281.25 10604.50 0.00
P 280 258.75 10025.25 9935.75
D 0 32.50 2351.25 0.00
S 0 132.75 4911.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
15 57.25 2979.00 0.00
Other 2 14.50 890.12 0.00
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Total 310 793.00 32492.62 9935.75
Center 04
Flag Claims Units Chgs Paid
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R 16 30.00 1475.25 0.00
U 0 0.00 0.00 0.00
B 174 509.75 20776.00 0.00
P 107 431.25 16407.75 16318.25
D 0 32.50 2351.25 0.00
S 0 132.75 4911.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
28 89.50 6836.25 0.00
Other 0 14.50 890.12 0.00
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Total 325 1240.25 53648.37 16318.25
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 16 43.75 1984.00 0.00
U 0 0.00 0.00 0.00
B 28 528.50 21469.75 0.00
P 0 431.25 16407.75 16318.25
D 0 32.50 2351.25 0.00
S 0 132.75 4911.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
78 132.25 8570.00 0.00
Other 0 14.50 890.12 0.00
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Total 122 1315.50 56584.62 16318.25
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 43.75 1984.00 0.00
U 0 0.00 0.00 0.00
B 12 535.50 21728.75 0.00
P 161 555.50 21081.00 20991.50
D 0 32.50 2351.25 0.00
S 0 132.75 4911.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
66 201.25 12927.00 225.00
Other 0 14.50 890.12 0.00
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Total 239 1515.75 65873.87 21216.50
Center 07
Flag Claims Units Chgs Paid
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R 12 52.75 2317.00 0.00
U 0 0.00 0.00 0.00
B 254 760.75 31229.25 0.00
P 9 564.00 21623.50 21534.00
D 0 32.50 2351.25 0.00
S 0 132.75 4911.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
22 233.25 14991.50 225.00
Other 0 14.50 890.12 0.00
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Total 297 1790.50 78314.37 21759.00
Center 09
Flag Claims Units Chgs Paid
-------------------------------------------------
R 10 68.00 3014.25 0.00
U 0 0.00 0.00 0.00
B 205 1010.75 45020.75 0.00
P 67 645.00 26628.00 26538.50
D 0 32.50 2351.25 0.00
S 0 132.75 4911.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
14 252.00 16002.75 225.00
Other 0 14.50 890.12 0.00
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Total 296 2155.50 98818.87 26763.50
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 74 145.00 6762.00 0.00
U 0 0.00 0.00 0.00
B 789 1732.00 75711.50 0.00
P 199 929.50 44299.25 44209.75
D 0 32.50 2351.25 0.00
S 7 137.00 5069.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 252.00 16002.75 225.00
Other 0 14.50 890.12 0.00
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Total 1069 3242.50 151085.87 44434.75
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 3 149.00 7005.00 0.00
U 0 0.00 0.00 0.00
B 199 1917.00 82784.50 0.00
P 0 929.50 44299.25 44209.75
D 0 32.50 2351.25 0.00
S 0 137.00 5069.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
36 288.50 18740.25 225.00
Other 0 14.50 890.12 0.00
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Total 238 3468.00 161139.37 44434.75
Center 52
Flag Claims Units Chgs Paid
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R 0 149.00 7005.00 0.00
U 0 0.00 0.00 0.00
B 67 1980.75 85623.00 0.00
P 101 1013.00 47699.50 47610.00
D 0 32.50 2351.25 0.00
S 15 147.00 5439.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
24 322.25 20955.00 225.00
Other 0 14.50 890.12 0.00
-------------------------------------------------
Total 207 3659.00 169962.87 47835.00
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 28 197.75 9751.75 0.00
U 0 0.00 0.00 0.00
B 21 2006.25 86642.50 0.00
P 87 1126.75 53312.50 53223.00
D 0 32.50 2351.25 0.00
S 0 147.00 5439.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
7 336.25 21929.00 225.00
Other 0 14.50 890.12 0.00
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Total 143 3861.00 180316.12 53448.00
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 198.75 9801.75 0.00
U 0 0.00 0.00 0.00
B 238 2210.00 95925.75 0.00
P 252 1333.50 61467.50 61378.00
D 0 32.50 2351.25 0.00
S 0 147.00 5439.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
26 364.75 23847.32 225.00
Other 0 14.50 890.12 0.00
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Total 517 4301.00 199722.69 61603.00
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 198.75 9801.75 0.00
U 0 0.00 0.00 0.00
B 25 2232.00 96739.75 0.00
P 63 1404.00 64324.00 64234.50
D 0 32.50 2351.25 0.00
S 0 147.00 5439.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
23 404.25 26546.57 225.00
Other 0 14.50 890.12 0.00
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Total 111 4433.00 206092.44 64459.50
Center 57
Flag Claims Units Chgs Paid
-------------------------------------------------
R 5 202.50 9940.50 0.00
U 0 0.00 0.00 0.00
B 35 2289.00 99319.25 0.00
P 0 1404.00 64324.00 64234.50
D 0 32.50 2351.25 0.00
S 0 147.00 5439.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
0 404.25 26546.57 225.00
Other 0 14.50 890.12 0.00
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Total 40 4493.75 208810.69 64459.50