CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 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-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 59.9200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.000000 239.6800 59.9200
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 3.500000 209.7200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 46 56.500000 3385.4800 59.9200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 25 25.000000 1338.7500 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 102.8700 34.2900
Subtotal (Total Children Is Unduplicated) 75 93.000000 5336.4200 57.3809
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Total 93.000000 5336.4200 57.3809
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Number of Children (Unduplicated) With at Least One Service 75
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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
81 93.000000 5336.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 81 93.000000 5336.4200 0.0000