CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 13 17.000000 943.5000 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.000000 1065.5000 96.8636
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
Subtotal (Total Children Is Unduplicated) 21 29.000000 2040.4700 70.3610
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Total 29.000000 2040.4700 70.3610
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Number of Children (Unduplicated) With at Least One Service 21
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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
25 29.000000 2040.4700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 25 29.000000 2040.4700 0.0000