CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 30.000000 2250.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
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 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 27 40.500000 2941.7000 72.6346
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 253.000000 6325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 22.000000 1100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 49.250000 3518.4200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 28 55.000000 3146.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 5 6.500000 464.3600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.500000 35.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 19 51.500000 2943.7400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 44.500000 3179.0800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 31 86.500000 4947.8000 57.2000
Subtotal (Total Children Is Unduplicated) 51 576.750000 26020.1200 45.1151
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Total 617.250000 28961.8200 46.9207
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Number of Children (Unduplicated) With at Least One Service 75
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Center 03
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 1 1.000000 10.0000 10.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1 1.000000 10.0000 10.0000
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
24 36.500000 2737.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 24 36.500000 2737.5000 0.0000
Center 57
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
198 579.750000 26214.3200 26349.1300
Other 0 0.000000 0.0000 0.0000
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Total 198 579.750000 26214.3200 26349.1300