CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 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
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 15.500000 1162.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 105.000000 7875.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 18 18.000000 5472.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 10 10.000000 471.2300 47.1230
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 7 7.000000 359.8700 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 14 14.000000 719.7400 51.4100
Subtotal (Total Children Is Unduplicated) 105 180.000000 16777.0700 93.2059
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 25 125.500000 9030.9800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 4 28.000000 1612.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 23 110.000000 7920.2800 72.0025
PHY-97110HM-PT SESSION BY PT ASST 5 42.000000 2406.6400 57.3010
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 153.500000 11045.8600 71.9600
Subtotal (Total Children Is Unduplicated) 66 459.000000 32016.5600 69.7529
-----------------------------------------------------------------------------------------------------------------------
Total 639.000000 48793.6300 76.3594
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 137
-----------------------------------------------------------------------------------------------------------------------
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 637 449.500000 33390.1700 24964.8800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.000000 143.9200 0.0000
T 0 0.000000 0.0000 0.0000
56 81.000000 7678.0000 0.0000
Other 205 106.500000 7581.5400 0.0000
---------------------------------------------------------
Total 900 639.000000 48793.6300 24964.8800