CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2025 ending 03/31/2025 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
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.500000 688.3300 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 8.000000 647.8400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 364.4100 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 6.500000 526.3700 80.9800
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.000000 728.8200 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.500000 2226.9500 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 1520.0000 304.0000
Subtotal (Total Children Is Unduplicated) 23 72.000000 6945.6600 96.4675
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Total 72.000000 6945.6600 96.4675
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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 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
57 72.000000 6945.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 57 72.000000 6945.6600 0.0000