CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 358 919.75 33975.25 36.94
Subtotal (Total Children Is Unduplicated) 358 919.75 33975.25 36.94
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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) 2 2.00 21.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.00 43.58 21.79
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.50 37.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.00 222.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 30.50 2287.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 9.00 675.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 3.00 225.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 23.50 1304.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 5.50 412.50 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.00 740.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.00 57.27 57.27
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.00 210.00 105.00
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.00 48.50 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
Subtotal (Total Children Is Unduplicated) 40 93.00 6500.86 69.90
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 27 137.00 6850.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 8.00 400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 3 16.00 1086.08 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 12.75 865.47 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 10.00 678.80 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.50 27.16 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 37 188.25 9960.31 52.91
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Total 1201.00 50436.42 42.00
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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 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 301 213.00 8283.25 0.00
P 123 93.00 3505.75 3505.75
D 3 1.25 46.25 0.00
S 75 54.75 2120.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
29 75.00 3933.68 0.00
Other 42 41.50 2593.26 0.00
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Total 573 478.50 20482.94 3505.75
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 117 73.75 2785.25 0.00
P 188 129.50 5436.75 4886.81
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 6 22.00 1100.00 1100.00
T 0 0.00 0.00 0.00
4 3.75 286.75 0.00
Other 0 0.00 0.00 0.00
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Total 315 229.00 9608.75 5986.81
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 252 122.25 4514.00 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
1 0.25 9.25 0.00
Other 0 0.00 0.00 0.00
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Total 253 122.50 4523.25 0.00
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 224 147.75 5466.75 0.00
P 20 16.25 601.25 601.25
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
58 55.00 3137.07 0.00
Other 0 0.00 0.00 0.00
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Total 302 219.00 9205.07 601.25
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 43 27.50 1017.50 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
5 5.00 323.50 0.00
Other 0 0.00 0.00 0.00
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Total 48 32.50 1341.00 0.00
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
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 13 12.25 547.25 547.25
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 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 13 12.25 547.25 547.25
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 41 35.00 1311.75 0.00
P 13 17.75 986.75 986.75
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
21 20.75 1050.91 0.00
Other 0 0.00 0.00 0.00
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Total 75 73.50 3349.41 986.75
Center 54
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 17 13.00 572.00 0.00
P 19 17.75 695.75 695.75
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 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 36 30.75 1267.75 695.75
Center 55
Flag Claims Units Chgs Paid
-------------------------------------------------
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 6 3.00 111.00 111.00
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 0.00 0.00 0.00
Other 0 0.00 0.00 0.00
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Total 6 3.00 111.00 111.00