CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:LEA
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 16.000000 1295.6800 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 60.000000 4858.8000 80.9800
Subtotal (Total Children Is Unduplicated) 38 76.000000 6154.4800 80.9800
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Total 76.000000 6154.4800 80.9800
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Number of Children (Unduplicated) With at Least One Service 38
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Center 52
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
38 76.000000 6154.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 38 76.000000 6154.4800 0.0000