CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 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
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 13.500000 749.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 6.000000 450.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 2240.0000 280.0000
Subtotal (Total Children Is Unduplicated) 27 29.500000 3550.2500 120.3475
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Total 29.500000 3550.2500 120.3475
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Number of Children (Unduplicated) With at Least One Service 27
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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 5 3.500000 438.2500 1108.4600
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
30 26.000000 3112.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 35 29.500000 3550.2500 1108.4600