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
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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.000000 458.9700 76.4950
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 7.000000 533.9700 76.2814
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 12.500000 937.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 74.000000 5557.3500 75.0993
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 3648.0000 304.0000
Subtotal (Total Children Is Unduplicated) 60 113.500000 11285.7900 99.4343
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Total 113.500000 11285.7900 99.4343
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Number of Children (Unduplicated) With at Least One Service 60
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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 32 43.000000 4845.9400 7385.2200
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
50 70.500000 6439.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 82 113.500000 11285.7900 7385.2200