CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 2.500000 187.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 72 141.500000 10612.5000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 304.0000 304.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 4082.7900 272.1860
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 227.9300 45.5860
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 3 3.000000 133.6500 44.5500
Subtotal (Total Children Is Unduplicated) 94 181.000000 16212.0200 89.5692
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 16.000000 800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 104.000000 7188.7200 69.1223
OCCT-97530HM-OT SESSION BY OT ASST 5 18.000000 1029.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 21 103.500000 7153.1600 69.1127
PHY-97110HM-PT SESSION BY PT ASST 1 11.000000 628.7600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 136.000000 9715.8400 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 57.2000 57.2000
Subtotal (Total Children Is Unduplicated) 57 389.500000 26573.2800 68.2241
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Total 570.500000 42785.3000 74.9961
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Number of Children (Unduplicated) With at Least One Service 135
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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 72 154.000000 10337.6900 3722.1000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 29.000000 1671.7600 0.0000
T 0 0.000000 0.0000 0.0000
92 160.000000 15186.7900 0.0000
Other 92 227.500000 15589.0600 1078.7600
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Total 264 570.500000 42785.3000 4800.8600