CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2023 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-96111GT-DEVELOPMENTAL EVALUATION 1 0.500000 25.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 3.500000 194.2500 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 151 136.500000 7575.7500 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 72 72.000000 5482.8000 76.1500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
Subtotal (Total Children Is Unduplicated) 189 213.500000 13309.2700 62.3385
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 201.000000 5025.0000 25.0000
Subtotal (Total Children Is Unduplicated) 17 201.000000 5025.0000 25.0000
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Total 414.500000 18334.2700 44.2323
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Number of Children (Unduplicated) With at Least One Service 206
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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
247 414.500000 18334.2700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 247 414.500000 18334.2700 0.0000