CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 9 13.500000 749.2500 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 228.4500 76.1500
Subtotal (Total Children Is Unduplicated) 13 20.500000 1194.2000 58.2537
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Total 20.500000 1194.2000 58.2537
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Number of Children (Unduplicated) With at Least One Service 13
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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
15 20.500000 1194.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15 20.500000 1194.2000 0.0000