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
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 7 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 20.500000 1137.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 28.000000 2100.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 27 27.000000 7560.0000 280.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 420.0000 420.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 1440.0000 180.0000
Subtotal (Total Children Is Unduplicated) 63 89.500000 13013.2500 145.3994
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Total 89.500000 13013.2500 145.3994
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Number of Children (Unduplicated) With at Least One Service 63
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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 26 26.000000 3122.0000 4637.8200
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
72 63.500000 9891.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 98 89.500000 13013.2500 4637.8200