CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 4.500000 337.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 36.500000 2737.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 26 42.000000 3126.4100 74.4383
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 279.000000 6975.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 8.000000 400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 9.500000 683.6200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 5 9.500000 547.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 4 12.500000 899.5000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 7 12.500000 719.5000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 18.500000 1331.2600 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 11.500000 662.4000 57.6000
Subtotal (Total Children Is Unduplicated) 21 365.000000 12418.4800 34.0232
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Total 407.000000 15544.8900 38.1938
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Number of Children (Unduplicated) With at Least One Service 46
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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
25 41.000000 3075.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 25 41.000000 3075.0000 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
79 366.000000 12469.8900 12469.8900
Other 0 0.000000 0.0000 0.0000
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Total 79 366.000000 12469.8900 12469.8900