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
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 0.500000 25.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 3.500000 194.2500 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 126 114.000000 6327.0000 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 62 62.000000 4721.3000 76.1500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
Subtotal (Total Children Is Unduplicated) 160 181.000000 11299.0200 62.4255
-----------------------------------------------------------------------------------------------------------------------
Total 181.000000 11299.0200 62.4255
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 160
-----------------------------------------------------------------------------------------------------------------------
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
194 181.000000 11299.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 194 181.000000 11299.0200 0.0000