CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 5 5.000000 375.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.500000 249.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 39.000000 2925.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 4256.0000 304.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 55 81.500000 8823.6000 108.2650
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 43.500000 3107.6400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 7.000000 400.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 42.000000 2916.4800 69.4400
PHY-97110HM-PT SESSION BY PT ASST 1 6.000000 342.9600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 92.500000 6608.2000 71.4400
Subtotal (Total Children Is Unduplicated) 49 197.000000 13675.6800 69.4197
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Total 278.500000 22499.2800 80.7874
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Number of Children (Unduplicated) With at Least One Service 92
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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 35 65.000000 4416.8700 1640.8300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 11 28.000000 1843.2000 0.0000
T 0 0.000000 0.0000 0.0000
59 64.500000 7955.7500 0.0000
Other 61 121.000000 8283.4600 0.0000
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Total 166 278.500000 22499.2800 1640.8300