CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.000000 458.9700 76.4950
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 7.000000 533.9700 76.2814
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 12.500000 937.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 74.000000 5557.3500 75.0993
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 3648.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 18 18.000000 945.4800 52.5267
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 13 13.000000 625.0300 48.0792
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 25 25.000000 1298.6500 51.9460
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 112 177.500000 14572.9300 82.1010
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 35 182.000000 12935.4900 71.0741
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 8 41.000000 2369.1200 57.7834
PHY-97110-PT SESSION BY LICENSED PT 30 124.500000 9267.9000 74.4410
PHY-97110HM-PT SESSION BY PT ASST 9 42.500000 2446.3000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 193.000000 14323.5200 74.2151
Subtotal (Total Children Is Unduplicated) 85 584.000000 41414.2900 70.9149
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Total 761.500000 55987.2200 73.5223
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Number of Children (Unduplicated) With at Least One Service 147
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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 790 478.000000 34948.1700 16857.1400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 16 13.500000 937.4200 0.0000
T 0 0.000000 0.0000 0.0000
54 74.500000 6645.4900 0.0000
Other 279 195.500000 13456.1400 0.0000
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Total 1139 761.500000 55987.2200 16857.1400