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
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 2 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.000000 222.0000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 26.000000 1443.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 17.000000 1275.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 21.000000 5880.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 900.0000 180.0000
Subtotal (Total Children Is Unduplicated) 56 74.500000 9832.5000 131.9799
-----------------------------------------------------------------------------------------------------------------------
Total 74.500000 9832.5000 131.9799
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 56
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 302.5600
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
80 73.500000 9552.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 81 74.500000 9832.5000 302.5600