CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.000000 277.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 14.000000 1050.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 79.000000 5925.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.000000 3344.0000 304.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 7 7.000000 359.8700 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 9 9.000000 462.6900 51.4100
Subtotal (Total Children Is Unduplicated) 90 143.500000 12594.2500 87.7648
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 23 96.500000 6944.1400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 7.000000 200.3200 28.6171
PHY-97110-PT SESSION BY LICENSED PT 21 80.500000 5792.7800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 2 13.000000 748.2800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 144.500000 10398.2200 71.9600
Subtotal (Total Children Is Unduplicated) 59 341.500000 24083.7400 70.5234
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Total 485.000000 36677.9900 75.6247
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Number of Children (Unduplicated) With at Least One Service 126
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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 36 74.500000 4858.5600 4432.6700
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
85 118.500000 11298.3600 0.0000
Other 136 292.000000 20521.0700 555.1300
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Total 257 485.000000 36677.9900 4987.8000