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:TPIN
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-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 15.500000 1162.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 608.0000 304.0000
Subtotal (Total Children Is Unduplicated) 12 17.500000 1770.5000 101.1714
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Total 17.500000 1770.5000 101.1714
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Number of Children (Unduplicated) With at Least One Service 12
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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 5 6.000000 679.0000 1090.5800
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 11.500000 1091.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14 17.500000 1770.5000 1090.5800