CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 6.000000 450.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 94.000000 7050.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 5776.0000 304.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 9 9.000000 386.1300 42.9033
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 9 9.000000 462.6900 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 7 7.000000 359.8700 51.4100
Subtotal (Total Children Is Unduplicated) 95 157.500000 15285.8300 97.0529
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 24 95.500000 6699.8000 70.1550
OCCT-97530HM-OT SESSION BY OT ASST 3 18.000000 1036.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 22 96.500000 6559.1400 67.9704
PHY-97110HM-PT SESSION BY PT ASST 13 16.250000 935.3500 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 80.250000 5774.7900 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 35.9800 71.9600
Subtotal (Total Children Is Unduplicated) 66 307.000000 21041.8600 68.5403
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Total 464.500000 36327.6900 78.2082
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Number of Children (Unduplicated) With at Least One Service 141
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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 77.000000 4703.6700 3084.5700
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
121 146.000000 14968.8000 831.0800
Other 122 241.500000 16655.2200 604.4400
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Total 278 464.500000 36327.6900 4520.0900