CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 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 302 748.750000 27685.2500 36.9753
Subtotal (Total Children Is Unduplicated) 302 748.750000 27685.2500 36.9753
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 8.8300 8.8300
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 10.8000 10.8000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.7900 21.7900
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 20.000000 1500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 12.500000 937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 20.500000 1137.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 30.000000 2250.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 225.5000 112.7500
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 4 4.000000 291.1200 72.7800
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 5 5.000000 250.7500 50.1500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 9 9.000000 450.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 52 122.000000 8185.0400 67.0905
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 21 124.000000 6200.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 14.500000 984.2600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 4 10.000000 678.8000 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 12.500000 848.5000 67.8800
Subtotal (Total Children Is Unduplicated) 30 173.000000 9311.5600 53.8240
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Total 1043.750000 45181.8500 43.2880
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Number of Children (Unduplicated) With at Least One Service 304
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 38 16.500000 686.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 315 226.000000 8835.0000 0.0000
P 65 47.500000 2040.5000 1965.5000
D 0 0.000000 0.0000 0.0000
S 3 3.250000 158.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 14 11.500000 832.4400 0.0000
---------------------------------------------------------
Total 435 304.750000 12552.1900 1965.5000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 62 40.750000 1507.7500 0.0000
P 64 50.750000 1934.7500 1859.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 19.000000 950.0000 950.0000
T 0 0.000000 0.0000 0.0000
1 1.000000 185.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 132 111.500000 4577.5000 2809.7500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 280 155.750000 6061.6200 0.0000
P 6 6.500000 387.5000 387.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 7.250000 420.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 290 169.500000 6869.3700 387.5000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 224 136.500000 5050.5000 0.0000
P 1 0.500000 18.5000 18.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
126 114.250000 6267.3500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 351 251.250000 11336.3500 18.5000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3 0.750000 27.7500 0.0000
P 1 0.250000 9.2500 9.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 1.000000 37.0000 9.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 54 41.750000 1624.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 6.000000 350.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 59 47.750000 1974.2500 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 10 5.250000 207.2500 207.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10 5.250000 207.2500 207.2500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 4.000000 148.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 33.000000 1405.0000 0.0000
P 33 39.000000 2114.2500 2114.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
50 49.500000 2590.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 110 125.500000 6257.9100 2114.2500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 13 8.500000 361.0000 0.0000
P 13 8.750000 401.7500 401.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 10.000000 607.2800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 27.250000 1370.0300 401.7500