CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 17.000000 1018.6400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 39 61.000000 3436.3300 56.3333
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 32 32.000000 2278.6000 71.2063
Subtotal (Total Children Is Unduplicated) 75 110.000000 6733.5700 61.2143
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Total 110.000000 6733.5700 61.2143
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Number of Children (Unduplicated) With at Least One Service 75
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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
83 110.000000 6733.5700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 83 110.000000 6733.5700 0.0000