CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 Page: 1
List order: No List
Payclass Filters:OTHER
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-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 10.000000 599.2000 59.9200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 160.6500 53.5500
Subtotal (Total Children Is Unduplicated) 13 14.000000 819.7700 58.5550
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Total 14.000000 819.7700 58.5550
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Number of Children (Unduplicated) With at Least One Service 13
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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
14 14.000000 819.7700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14 14.000000 819.7700 0.0000