CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 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 5 7.000000 419.4400 59.9200
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 9.000000 539.2800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 49 62.500000 3745.0000 59.9200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 38 38.000000 2034.9000 53.5500
Subtotal (Total Children Is Unduplicated) 84 116.500000 6738.6200 57.8422
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Total 116.500000 6738.6200 57.8422
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Number of Children (Unduplicated) With at Least One Service 84
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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
99 116.500000 6738.6200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 99 116.500000 6738.6200 0.0000