CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 21 914.000000 22850.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 54.000000 2700.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 8 8.000000 571.5200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 10 36.000000 2057.7600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 38.500000 2714.7200 70.5122
Subtotal (Total Children Is Unduplicated) 27 1050.500000 30894.0000 29.4089
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Total 1050.500000 30894.0000 29.4089
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Number of Children (Unduplicated) With at Least One Service 27
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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 3 16.500000 467.8800 467.8800
124 1034.000000 30426.1200 29887.2800
Other 0 0.000000 0.0000 0.0000
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Total 127 1050.500000 30894.0000 30355.1600