CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 19.000000 1425.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 9 9.000000 2736.0000 304.0000
Subtotal (Total Children Is Unduplicated) 20 28.000000 4161.0000 148.6071
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Total 28.000000 4161.0000 148.6071
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Number of Children (Unduplicated) With at Least One Service 20
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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 0 0.000000 0.0000 0.0000
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
27 28.000000 4161.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 27 28.000000 4161.0000 0.0000