CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Payclass Filters:TPIN
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 23 20.500000 1137.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 12.000000 900.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 4760.0000 280.0000
Subtotal (Total Children Is Unduplicated) 39 49.500000 6797.7500 137.3283
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Total 49.500000 6797.7500 137.3283
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Number of Children (Unduplicated) With at Least One Service 39
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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 1 1.000000 280.0000 375.1800
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
55 48.500000 6517.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 56 49.500000 6797.7500 375.1800