CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 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 7 7.000000 339.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.000000 194.0000 48.5000
Subtotal (Total Children Is Unduplicated) 8 12.000000 582.0000 48.5000
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EI Services,Class #03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 272.000000 6800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 88 2849.000000 71225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 285.000000 14250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 48 285.750000 19396.7100 67.8800
PHY-97110-PT SESSION BY LICENSED PT 61 230.000000 15612.4000 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 80 354.750000 24080.4300 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 4 2.000000 26.4000 13.2000
Subtotal (Total Children Is Unduplicated) 144 4278.500000 151390.9400 35.3841
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Total 4290.500000 151972.9400 35.4208
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Number of Children (Unduplicated) With at Least One Service 144
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Center 04
Flag Claims Units Chgs Paid
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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
451 2991.500000 93150.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 451 2991.500000 93150.4200 0.0000
Center 57
Flag Claims Units Chgs Paid
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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
298 1299.000000 58822.5200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 298 1299.000000 58822.5200 0.0000