CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 20 40.000000 3191.3600 79.7840
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 43.000000 3368.5200 78.3377
Subtotal (Total Children Is Unduplicated) 42 83.000000 6559.8800 79.0347
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Total 83.000000 6559.8800 79.0347
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Number of Children (Unduplicated) With at Least One Service 42
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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
42 83.000000 6559.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 42 83.000000 6559.8800 0.0000