CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2025 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 7 11.000000 659.1200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 8.000000 479.3600 59.9200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 53.5500 53.5500
Subtotal (Total Children Is Unduplicated) 13 20.000000 1192.0300 59.6015
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.000000 81.0000 27.0000
Subtotal (Total Children Is Unduplicated) 1 3.000000 81.0000 27.0000
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Total 23.000000 1273.0300 55.3491
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Number of Children (Unduplicated) With at Least One Service 14
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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
17 23.000000 1273.0300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 17 23.000000 1273.0300 0.0000