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: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 14 19.500000 1164.0200 59.6933
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 49 74.500000 4194.4200 56.3009
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 38 38.000000 2712.9000 71.3921
Subtotal (Total Children Is Unduplicated) 91 132.000000 8071.3400 61.1465
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 97.000000 2519.0000 25.9691
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 17 98.000000 2590.9600 26.4384
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Total 230.000000 10662.3000 46.3578
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Number of Children (Unduplicated) With at Least One Service 108
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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
167 230.000000 10662.3000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 167 230.000000 10662.3000 0.0000