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:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 233.9700 77.9900
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 23.500000 1792.4000 76.2723
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 9 9.000000 2736.0000 304.0000
Subtotal (Total Children Is Unduplicated) 23 44.000000 5399.8700 122.7243
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Total 44.000000 5399.8700 122.7243
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Number of Children (Unduplicated) With at Least One Service 23
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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 15 17.500000 2469.4600 3193.7200
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
21 26.500000 2930.4100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 36 44.000000 5399.8700 3193.7200