CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Payclass Filters:OTHER
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-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 2.500000 145.3800 58.1520
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 13.500000 758.0900 56.1548
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 434.3000 72.3833
Subtotal (Total Children Is Unduplicated) 16 22.000000 1337.7700 60.8077
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Total 22.000000 1337.7700 60.8077
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Number of Children (Unduplicated) With at Least One Service 16
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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
18 22.000000 1337.7700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18 22.000000 1337.7700 0.0000