CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 48.500000 3637.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
Subtotal (Total Children Is Unduplicated) 32 53.000000 3975.0000 75.0000
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 46 1484.000000 37200.0000 25.0674
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 19.000000 950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.500000 107.9400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 5 10.500000 755.5800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 13 20.500000 1165.5900 56.8580
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 17.500000 1259.3000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 1.500000 107.9400 71.9600
Subtotal (Total Children Is Unduplicated) 48 1554.500000 41546.3500 26.7265
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Total 1607.500000 45521.3500 28.3181
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Number of Children (Unduplicated) With at Least One Service 80
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Center 04
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
58 1226.000000 31042.8900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 58 1226.000000 31042.8900 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
32 53.000000 3975.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 32 53.000000 3975.0000 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
65 328.500000 10503.4600 10528.4600
Other 0 0.000000 0.0000 0.0000
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Total 65 328.500000 10503.4600 10528.4600