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:TPIN
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
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 6.000000 450.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 94.000000 7050.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 5776.0000 304.0000
Subtotal (Total Children Is Unduplicated) 77 128.500000 13871.5000 107.9494
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Total 128.500000 13871.5000 107.9494
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Number of Children (Unduplicated) With at Least One Service 77
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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
101 128.500000 13871.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 101 128.500000 13871.5000 0.0000