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
Bill Flag Filter:RBPU
Eligibility Filter:All
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 12753 41411.00000 1530987.0000 36.9705
Subtotal (Total Children Is Unduplicated) 12753 41411.00000 1530987.0000 36.9705
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Screening, Eval, and Assessment,Class #02
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 2 2.000000 250.0000 125.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 106 175.000000 13125.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 24 29.500000 2212.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 25 31.000000 2325.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 61 96.500000 7237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 124 193.500000 10703.2500 55.3140
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1007 1414.500000 106087.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 187 287.500000 21562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 339 472.000000 35400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1353 2083.000000 115495.5000 55.4467
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 731 1122.500000 84150.0000 74.9666
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 21.000000 3162.5000 150.5952
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 6 6.000000 436.6800 72.7800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 315.0000 105.0000
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 8 8.000000 401.2000 50.1500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000000 291.0000 48.5000
SCREEN-T1023-INTERDISCIPLINARY SCREENING 86 86.000000 4300.0000 50.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 18.000000 873.0000 48.5000
Subtotal (Total Children Is Unduplicated) 2349 6060.000000 408570.6300 67.4209
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 319 1346.000000 67202.0000 49.9272
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 12 23.000000 1150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 89.250000 6058.2900 67.8800
PHY-97110-PT SESSION BY LICENSED PT 35 137.750000 9350.4700 67.8800
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 40.000000 2000.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 190.000000 12897.2000 67.8800
VISN-T1027SC-EI VISION SERVICES, INDIVIDUAL 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 419 1830.000000 98782.9600 53.9798
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Total 49301.000000 2038340.5900 41.3448
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Number of Children (Unduplicated) With at Least One Service 12887
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 920 653.500000 28005.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5900 4339.750000 175698.2500 0.0000
P 1303 984.000000 43136.5700 40894.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8123 5977.250000 246839.8200 40894.0000
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.000000 148.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 738 547.000000 20155.7500 0.0000
P 2 1.000000 37.0000 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 746 552.000000 20340.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.500000 462.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 149.000000 5665.0000 9.2500
P 2800 1890.000000 75092.7700 75087.0200
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 3034 2051.500000 81220.2700 75096.2700
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1944 2024.750000 78354.7500 0.0000
P 2657 2754.000000 109538.5000 106617.0200
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 4602 4779.500000 187921.0000 106617.0200
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2991 1758.250000 67368.9500 0.0000
P 33 39.000000 2775.0000 2775.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3024 1797.250000 70143.9500 2775.0000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 5.750000 212.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 4223 2825.250000 104515.7500 0.0000
P 65 42.750000 1581.7500 1581.7500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4299 2873.750000 106310.2500 1581.7500
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 99 84.750000 3135.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2312 1573.500000 63486.7500 0.0000
P 2456 1603.750000 65727.2500 61493.2500
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 4867 3262.000000 132349.7500 61493.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 11.500000 462.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 5712 5741.000000 260479.2800 0.0000
P 482 420.000000 16375.4000 16375.4700
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 6206 6172.500000 277317.1800 16375.4700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 9.000000 333.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 423 250.750000 9409.7500 0.0000
P 7907 5545.000000 237935.2500 237935.2500
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 8349 5804.750000 247678.0000 237935.2500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 4237 3012.250000 113893.9000 0.0000
P 2 1.500000 93.5000 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4243 3017.000000 114107.6500 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 20 10.750000 546.1500 0.0000
P 2822 1975.750000 90075.8100 89850.8100
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 2842 1986.500000 90621.9600 89850.8100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 97 107.500000 4255.5000 311.0000
U 0 0.000000 0.0000 0.0000
B 1346 1296.000000 54015.7500 0.0000
P 699 834.000000 41830.5000 40180.5000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2142 2237.500000 100101.7500 40491.5000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 18.250000 760.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3189 2353.500000 98726.0800 0.0000
P 2454 1791.500000 75385.4300 75262.8000
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 5668 4163.250000 174871.5100 75262.8000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 11.250000 416.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 41 50.250000 3227.2500 0.0000
P 1616 1482.000000 57091.7500 57082.5000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1672 1543.500000 60735.2500 57082.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 19.500000 721.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2820 3061.250000 126986.0000 0.0000
P 1 2.000000 74.0000 74.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2837 3082.750000 127781.5000 74.0000