CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 16 613.000000 15325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 64.000000 3200.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 6.500000 325.0000 50.0000
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 6 7.000000 500.0800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 9 27.500000 1571.9000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 21.250000 1518.1000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.500000 200.2000 57.2000
Subtotal (Total Children Is Unduplicated) 23 744.750000 22754.6800 30.5534
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Total 744.750000 22754.6800 30.5534
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Number of Children (Unduplicated) With at Least One Service 23
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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
130 744.750000 22754.6800 22754.6800
Other 0 0.000000 0.0000 0.0000
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Total 130 744.750000 22754.6800 22754.6800