CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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 4 8.000000 600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 24 39.000000 2925.0000 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
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 30 50.000000 3678.1500 73.5630
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 484.000000 12100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 13.000000 650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 59.000000 2950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 34.500000 2464.6800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 22 61.000000 3489.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 6 9.500000 678.6800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 8 65.500000 3743.9800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 47.000000 3357.6800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 3.750000 267.9000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 24 93.000000 5319.6000 57.2000
Subtotal (Total Children Is Unduplicated) 49 870.250000 35021.7200 40.2433
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Total 920.250000 38699.8700 42.0536
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Number of Children (Unduplicated) With at Least One Service 77
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Center 06
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
13 6.500000 464.3600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 13 6.500000 464.3600 0.0000
Center 52
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
28 47.000000 3525.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 28 47.000000 3525.0000 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
176 866.750000 34710.5100 34710.5100
Other 0 0.000000 0.0000 0.0000
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Total 176 866.750000 34710.5100 34710.5100