CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 2.000000 111.0000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 7.500000 416.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 16.500000 1237.5000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.000000 570.0000 190.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 3360.0000 280.0000
Subtotal (Total Children Is Unduplicated) 32 42.000000 5769.7500 137.3750
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Total 42.000000 5769.7500 137.3750
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Number of Children (Unduplicated) With at Least One Service 32
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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 9 8.000000 1310.5000 1816.0900
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
38 34.000000 4459.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 47 42.000000 5769.7500 1816.0900