CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2025 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 5 10.000000 809.8000 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 647.8400 80.9800
Subtotal (Total Children Is Unduplicated) 9 18.000000 1457.6400 80.9800
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Total 18.000000 1457.6400 80.9800
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Number of Children (Unduplicated) With at Least One Service 9
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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
9 18.000000 1457.6400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9 18.000000 1457.6400 0.0000