CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 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
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 15.500000 1162.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 105.000000 7875.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 18 18.000000 5472.0000 304.0000
Subtotal (Total Children Is Unduplicated) 82 146.000000 15072.0000 103.2329
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Total 146.000000 15072.0000 103.2329
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Number of Children (Unduplicated) With at Least One Service 82
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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 46 65.000000 7394.0000 10640.2200
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
56 81.000000 7678.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 102 146.000000 15072.0000 10640.2200