CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 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
EVAL-96111-DEVELOPMENTAL EVALUATION 4 2.500000 125.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 0.500000 25.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 7.000000 388.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 55.5000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 328 277.000000 15373.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 100 80.500000 4467.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.000000 225.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 167 167.000000 12704.2400 76.0733
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 94.4100 31.4700
Subtotal (Total Children Is Unduplicated) 530 545.000000 33692.1500 61.8205
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 40 669.000000 16725.0000 25.0000
Subtotal (Total Children Is Unduplicated) 40 669.000000 16725.0000 25.0000
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Total 1214.000000 50417.1500 41.5298
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Number of Children (Unduplicated) With at Least One Service 568
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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
686 1214.000000 50417.1500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 686 1214.000000 50417.1500 0.0000