CMS/EIP Fiscal Report Center: 57
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 17 233.000000 5825.0000 25.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 38.000000 2734.4800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 5 31.000000 1785.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 5 15.000000 1079.4000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 17 50.000000 2878.0000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 44.500000 3202.2200 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 20 62.000000 3571.2000 57.6000
Subtotal (Total Children Is Unduplicated) 38 473.500000 21075.9000 44.5109
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Total 473.500000 21075.9000 44.5109
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Number of Children (Unduplicated) With at Least One Service 38
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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
111 473.500000 21075.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 111 473.500000 21075.9000 0.0000