CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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 353 902.75 33392.50 36.99
Subtotal (Total Children Is Unduplicated) 353 902.75 33392.50 36.99
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.00 225.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.00 150.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 19.50 1462.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.50 112.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 11.50 862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 19.00 1054.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 19.00 1425.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.00 370.00 185.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.00 291.12 72.78
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 5 5.00 250.75 50.15
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.00 48.50 48.50
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.00 48.50 48.50
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
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.00 145.50 48.50
Subtotal (Total Children Is Unduplicated) 49 104.50 7199.87 68.90
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 17 134.00 6700.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 6.00 300.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 11.00 746.68 67.88
PHY-97110-PT SESSION BY LICENSED PT 4 15.50 1052.14 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 3.00 150.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.50 373.34 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 23 179.00 9374.96 52.37
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Total 1186.25 49967.33 42.12
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Number of Children (Unduplicated) With at Least One Service 362
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Center 01
Flag Claims Units Chgs Paid
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R 13 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 123 86.25 3220.00 0.00
P 283 208.00 8206.50 8206.50
D 6 5.25 194.25 0.00
S 43 30.25 1119.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
30 75.50 3893.66 0.00
Other 49 64.00 4054.93 0.00
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Total 547 477.00 20975.34 8206.50
Center 04
Flag Claims Units Chgs Paid
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R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 302 289.50 10834.75 0.00
P 23 227.25 8918.75 8918.75
D 0 5.25 194.25 0.00
S 0 30.25 1119.25 0.00
H 4 14.00 717.88 717.88
T 0 0.00 0.00 0.00
13 85.25 4618.41 0.00
Other 0 64.00 4054.93 0.00
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Total 342 723.25 30744.97 9636.63
Center 05
Flag Claims Units Chgs Paid
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R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 280 430.25 16070.25 0.00
P 0 227.25 8918.75 8918.75
D 0 5.25 194.25 0.00
S 0 30.25 1119.25 0.00
H 0 14.00 717.88 717.88
T 0 0.00 0.00 0.00
18 103.25 5610.28 0.00
Other 0 64.00 4054.93 0.00
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Total 298 882.00 36972.34 9636.63
Center 06
Flag Claims Units Chgs Paid
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R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 85 484.00 18059.00 101.75
P 195 351.00 13497.50 13497.50
D 0 5.25 194.25 0.00
S 0 30.25 1119.25 0.00
H 0 14.00 717.88 717.88
T 0 0.00 0.00 0.00
30 131.50 7412.52 0.00
Other 0 64.00 4054.93 0.00
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Total 310 1087.75 45342.08 14317.13
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 0 484.00 18059.00 101.75
P 3 353.25 13580.75 13580.75
D 0 5.25 194.25 0.00
S 0 30.25 1119.25 0.00
H 0 14.00 717.88 717.88
T 0 0.00 0.00 0.00
0 131.50 7412.52 0.00
Other 0 64.00 4054.93 0.00
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Total 3 1090.00 45425.33 14400.38
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 0 484.00 18059.00 101.75
P 3 357.50 13738.00 13738.00
D 0 5.25 194.25 0.00
S 0 30.25 1119.25 0.00
H 0 14.00 717.88 717.88
T 0 0.00 0.00 0.00
0 131.50 7412.52 0.00
Other 0 64.00 4054.93 0.00
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Total 3 1094.25 45582.58 14557.63
Center 51
Flag Claims Units Chgs Paid
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R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 14 492.00 18355.00 101.75
P 0 357.50 13738.00 13738.00
D 0 5.25 194.25 0.00
S 0 30.25 1119.25 0.00
H 0 14.00 717.88 717.88
T 0 0.00 0.00 0.00
0 131.50 7412.52 0.00
Other 0 64.00 4054.93 0.00
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Total 14 1102.25 45878.58 14557.63
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 2 492.75 18382.75 101.75
P 0 357.50 13738.00 13738.00
D 0 5.25 194.25 0.00
S 0 30.25 1119.25 0.00
H 0 14.00 717.88 717.88
T 0 0.00 0.00 0.00
0 131.50 7412.52 0.00
Other 0 64.00 4054.93 0.00
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Total 2 1103.00 45906.33 14557.63
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 8 504.00 18990.00 101.75
P 12 367.75 14265.00 14265.00
D 0 5.25 194.25 0.00
S 0 30.25 1119.25 0.00
H 0 14.00 717.88 717.88
T 0 0.00 0.00 0.00
34 165.50 9106.52 0.00
Other 0 64.00 4054.93 0.00
-------------------------------------------------
Total 54 1158.50 48734.58 15084.63
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 27 522.50 19804.50 101.75
P 1 368.00 14274.25 14274.25
D 0 5.25 194.25 0.00
S 0 30.25 1119.25 0.00
H 0 14.00 717.88 717.88
T 0 0.00 0.00 0.00
0 165.50 9106.52 0.00
Other 0 64.00 4054.93 0.00
-------------------------------------------------
Total 28 1177.25 49558.33 15093.88
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 0 522.50 19804.50 101.75
P 5 376.00 14608.25 14608.25
D 0 5.25 194.25 0.00
S 0 30.25 1119.25 0.00
H 0 14.00 717.88 717.88
T 0 0.00 0.00 0.00
1 166.50 9181.52 0.00
Other 0 64.00 4054.93 0.00
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Total 6 1186.25 49967.33 15427.88