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: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
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 16.500000 1237.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 2128.0000 304.0000
Subtotal (Total Children Is Unduplicated) 18 24.500000 3440.5000 140.4286
-----------------------------------------------------------------------------------------------------------------------
Total 24.500000 3440.5000 140.4286
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 18
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
21 24.500000 3440.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 21 24.500000 3440.5000 0.0000