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:Program Patients
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 10 12.000000 971.7600 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 3 3.500000 283.4300 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 18.000000 1457.6400 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 35 43.000000 3482.1400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 9.500000 769.3100 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 20 26.500000 2145.9700 80.9800
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 27.000000 2186.4600 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 62 110.000000 8907.8000 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 5168.0000 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) 106 289.000000 26874.3800 92.9909
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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 354.000000 31852.3800 89.9785
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Number of Children (Unduplicated) With at Least One Service 117
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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
219 276.000000 26118.9500 0.0000
Other 100 61.000000 4601.0000 0.0000
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Total 337 354.000000 31852.3800 871.9500