CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2025 ending 03/31/2025 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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 10.500000 850.2900 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 242.9400 80.9800
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 3.000000 242.9400 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 2 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.500000 769.3100 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 28 35.000000 2834.3000 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 5.000000 404.9000 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 20.000000 1619.6000 80.9800
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 18.000000 1457.6400 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 82.500000 6680.8500 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 3648.0000 304.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 232.4400 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 6 6.000000 348.6600 58.1100
Subtotal (Total Children Is Unduplicated) 83 217.000000 19928.7200 91.8374
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 9 15.000000 1219.8000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 4 12.000000 781.4400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 5 9.000000 731.8800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 2 7.000000 455.8400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 22.000000 1789.0400 81.3200
Subtotal (Total Children Is Unduplicated) 22 65.000000 4978.0000 76.5846
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Total 282.000000 24906.7200 88.3217
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Number of Children (Unduplicated) With at Least One Service 94
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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 14 13.000000 871.9500 871.9500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 4.000000 260.4800 0.0000
T 0 0.000000 0.0000 0.0000
162 204.000000 19173.2900 0.0000
Other 100 61.000000 4601.0000 0.0000
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Total 280 282.000000 24906.7200 871.9500