CMS/EIP Fiscal Report Center: 57
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 5 8.000000 408.4000 51.0500
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 20 675.000000 16875.0000 25.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 13.000000 928.7200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 10 10.500000 600.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 6 3.500000 250.0400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 12 33.750000 1929.1500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 14.750000 1053.7400 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 11 18.500000 1058.2000 57.2000
Subtotal (Total Children Is Unduplicated) 37 769.000000 22695.4500 29.5129
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Total 777.000000 23103.8500 29.7347
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Number of Children (Unduplicated) With at Least One Service 39
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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
105 777.000000 23103.8500 23103.8500
Other 0 0.000000 0.0000 0.0000
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Total 105 777.000000 23103.8500 23103.8500