CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Payclass Filters:OTHER
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-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 22.500000 1248.7500 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 761.5000 76.1500
Subtotal (Total Children Is Unduplicated) 29 32.500000 2010.2500 61.8538
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Total 32.500000 2010.2500 61.8538
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Number of Children (Unduplicated) With at Least One Service 29
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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
35 32.500000 2010.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 35 32.500000 2010.2500 0.0000