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
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 3 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 30.000000 1665.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 27.500000 2062.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 31 31.000000 8680.0000 280.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 180.0000 180.0000
Subtotal (Total Children Is Unduplicated) 72 95.500000 12979.0000 135.9058
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Total 95.500000 12979.0000 135.9058
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Number of Children (Unduplicated) With at Least One Service 72
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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 17 14.000000 2316.7500 4215.2200
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
87 81.500000 10662.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 104 95.500000 12979.0000 4215.2200