CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/16/2012 Page: 1
List order: No List
Payclass Filters:LEA
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 194.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.000000 242.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.000000 194.0000 48.5000
Subtotal (Total Children Is Unduplicated) 10 14.000000 679.0000 48.5000
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EI Services,Class #03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 4 268.000000 6700.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 104 1584.000000 39600.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 22 140.000000 7000.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 49 138.750000 9418.3500 67.8800
PHY-97110-PT SESSION BY LICENSED PT 62 130.000000 8824.4000 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 89 198.250000 13457.2100 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.500000 6.6000 13.2000
Subtotal (Total Children Is Unduplicated) 173 2459.500000 85006.5600 34.5625
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Total 2473.500000 85685.5600 34.6414
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Number of Children (Unduplicated) With at Least One Service 174
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Center 04
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 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
355 2025.000000 61828.5200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 355 2025.000000 61828.5200 0.0000
Center 09
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 7 25.000000 1643.3600 1643.3600
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
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Total 7 25.000000 1643.3600 1643.3600
Center 57
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 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
157 423.500000 22213.6800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 157 423.500000 22213.6800 0.0000