CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 3 4.000000 204.2000 51.0500
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 31 1075.000000 26875.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 237.000000 11850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 45 107.000000 7644.0800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 51 142.000000 8122.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 23 43.500000 3107.6400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 29 94.000000 5373.0400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 86.000000 6143.8400 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 70 226.500000 12955.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 1 6.000000 83.2800 13.8800
Subtotal (Total Children Is Unduplicated) 130 2017.000000 82155.0800 40.7313
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Total 2021.000000 82359.2800 40.7517
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Number of Children (Unduplicated) With at Least One Service 130
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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
35 269.000000 9896.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 35 269.000000 9896.1400 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
560 1752.000000 72463.1400 69627.4800
Other 0 0.000000 0.0000 0.0000
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Total 560 1752.000000 72463.1400 69627.4800