CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 12 16.500000 931.2200 56.4376
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 648.5000 64.8500
Subtotal (Total Children Is Unduplicated) 21 27.500000 1635.2200 59.4625
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Total 27.500000 1635.2200 59.4625
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Number of Children (Unduplicated) With at Least One Service 21
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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
23 27.500000 1635.2200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 23 27.500000 1635.2200 0.0000