CMS/EIP Fiscal Report Statewide
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
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 23.500000 1762.5000 75.0000
Subtotal (Total Children Is Unduplicated) 20 31.500000 2362.5000 75.0000
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 84 3319.000000 82975.0000 25.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 45.500000 3274.1800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 5 31.000000 1785.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 18 35.500000 2554.5800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 36 90.000000 5180.4000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 97.000000 6980.1200 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 20 62.000000 3571.2000 57.6000
SPL-92508HA-GROUP SPL SESSION PER CHILD 3 6.000000 83.7600 13.9600
Subtotal (Total Children Is Unduplicated) 105 3686.000000 106404.8400 28.8673
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Total 3717.500000 108767.3400 29.2582
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Number of Children (Unduplicated) With at Least One Service 125
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Center 04
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
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
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
20 31.500000 2362.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 20 31.500000 2362.5000 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
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