CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 3 6.000000 450.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 49.000000 3675.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 29 56.000000 4176.0500 74.5723
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 81 5534.000000 138350.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 15 170.000000 8500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 90 218.500000 15609.6400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 67 158.000000 9037.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 35 56.500000 4036.3600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 49 118.750000 6787.7500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 82 146.250000 10448.1000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 105 276.500000 15815.8000 57.2000
Subtotal (Total Children Is Unduplicated) 230 6678.500000 208585.2500 31.2324
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Total 6734.500000 212761.3000 31.5927
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Number of Children (Unduplicated) With at Least One Service 258
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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
315 5397.000000 141397.5600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 315 5397.000000 141397.5600 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
28 55.000000 4125.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 28 55.000000 4125.0000 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
624 1282.500000 67238.7400 67238.7400
Other 0 0.000000 0.0000 0.0000
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Total 624 1282.500000 67238.7400 67238.7400