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:Program Patients
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 64 98.000000 5469.9400 55.8157
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 57 57.000000 4024.1500 70.5991
Subtotal (Total Children Is Unduplicated) 109 156.000000 9549.5900 61.2153
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 15 50.000000 1250.0000 25.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 15 51.000000 1321.9600 25.9208
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Total 207.000000 10871.5500 52.5196
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Number of Children (Unduplicated) With at Least One Service 124
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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
174 207.000000 10871.5500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 174 207.000000 10871.5500 0.0000