CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.000000 388.5000 55.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 54.500000 3024.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.000000 4255.0000 185.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 210.0000 105.0000
Subtotal (Total Children Is Unduplicated) 61 89.500000 8103.2500 90.5391
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Total 89.500000 8103.2500 90.5391
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Number of Children (Unduplicated) With at Least One Service 61
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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 26 25.500000 2769.5000 4959.5700
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
60 64.000000 5333.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 86 89.500000 8103.2500 4959.5700