CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 26 40.000000 3000.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 31 46.500000 3439.6000 73.9699
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 216.000000 5400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 10.000000 500.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 39.000000 1950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 3.500000 250.0400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 4 27.000000 1544.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 11.000000 785.8400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 32.500000 1857.7000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 19.500000 1393.0800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 28.500000 1630.2000 57.2000
Subtotal (Total Children Is Unduplicated) 25 387.000000 15311.2600 39.5640
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Total 433.500000 18750.8600 43.2546
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Number of Children (Unduplicated) With at Least One Service 54
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Center 06
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
6 3.000000 214.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6 3.000000 214.3200 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
29 44.500000 3337.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 29 44.500000 3337.5000 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
65 386.000000 15199.0400 15199.0400
Other 0 0.000000 0.0000 0.0000
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Total 65 386.000000 15199.0400 15199.0400