CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 8.500000 637.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 17.000000 1275.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 1900.1500 271.4500
Subtotal (Total Children Is Unduplicated) 24 34.000000 3895.9000 114.5853
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Total 34.000000 3895.9000 114.5853
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Number of Children (Unduplicated) With at Least One Service 24
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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 2 2.500000 187.5000 509.8000
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
30 31.500000 3708.4000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 32 34.000000 3895.9000 509.8000