CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 67 3086.000000 77150.0000 25.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 7.500000 539.7000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 13 20.500000 1475.1800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 19 40.000000 2302.4000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 52.500000 3777.9000 71.9600
SPL-92508HA-GROUP SPL SESSION PER CHILD 3 6.000000 83.7600 13.9600
Subtotal (Total Children Is Unduplicated) 67 3212.500000 85328.9400 26.5615
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Total 3212.500000 85328.9400 26.5615
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Number of Children (Unduplicated) With at Least One Service 67
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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
209 3212.500000 85328.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 209 3212.500000 85328.9400 0.0000