CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.500000 1162.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 11 20.500000 1465.6500 71.4951
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 30 2537.000000 63425.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 9.000000 450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 35 27.000000 1928.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 38 30.500000 1744.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 7 5.000000 357.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 28 20.250000 1157.4900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 23.500000 1678.8400 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 38 28.500000 1630.2000 57.2000
Subtotal (Total Children Is Unduplicated) 117 2680.750000 72372.2100 26.9970
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Total 2701.250000 73837.8600 27.3347
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Number of Children (Unduplicated) With at Least One Service 126
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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
45 2480.000000 62000.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 45 2480.000000 62000.0000 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 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
9 17.500000 1312.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 17.500000 1312.5000 0.0000
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
201 203.750000 10525.3600 10525.3600
Other 0 0.000000 0.0000 0.0000
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Total 201 203.750000 10525.3600 10525.3600