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:OTHER
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
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 7.000000 419.4400 59.9200
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 6.000000 359.5200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 32 42.000000 2516.6400 59.9200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 29 29.000000 1552.9500 53.5500
Subtotal (Total Children Is Unduplicated) 61 84.000000 4848.5500 57.7208
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Total 84.000000 4848.5500 57.7208
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Number of Children (Unduplicated) With at Least One Service 61
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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
71 84.000000 4848.5500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 71 84.000000 4848.5500 0.0000