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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 88 139.500000 7742.2500 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 58 58.000000 4644.5500 80.0784
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 62.9400 31.4700
Subtotal (Total Children Is Unduplicated) 133 211.500000 13115.7400 62.0130
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Total 211.500000 13115.7400 62.0130
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Number of Children (Unduplicated) With at Least One Service 133
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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
156 211.500000 13115.7400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 156 211.500000 13115.7400 0.0000