CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
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 52 81.500000 4538.7200 55.6898
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 47 47.000000 3375.6500 71.8223
Subtotal (Total Children Is Unduplicated) 88 128.500000 7914.3700 61.5904
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 15 50.000000 1250.0000 25.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 15 51.000000 1321.9600 25.9208
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Total 179.500000 9236.3300 51.4559
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Number of Children (Unduplicated) With at Least One Service 103
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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
151 179.500000 9236.3300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 151 179.500000 9236.3300 0.0000