CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2019 ending 03/31/2019 Date of Report:05/04/2019 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 5 10.000000 750.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 48.500000 3637.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 42 71.500000 5051.1500 70.6455
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 72 4775.000000 119375.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 107.000000 5350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 123.000000 8787.1200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 36 95.000000 5434.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 36 77.500000 5536.6000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 41 107.500000 6144.7000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 60 139.000000 9930.1600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 51 132.500000 7586.1200 57.2537
SPL-92508-GROUP SPL SESSION PER CHILD 3 3.500000 48.5800 13.8800
Subtotal (Total Children Is Unduplicated) 153 5560.000000 168192.2800 30.2504
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Total 5631.500000 173243.4300 30.7633
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Number of Children (Unduplicated) With at Least One Service 185
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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
251 4605.250000 120350.2200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 251 4605.250000 120350.2200 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
30 58.500000 4387.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 30 58.500000 4387.5000 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
251 967.750000 48505.7100 49463.7100
Other 0 0.000000 0.0000 0.0000
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Total 251 967.750000 48505.7100 49463.7100