CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 12.000000 1962.5000 163.5417
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 1168.0000 292.0000
Subtotal (Total Children Is Unduplicated) 14 17.000000 3205.5000 188.5588
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Total 17.000000 3205.5000 188.5588
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Number of Children (Unduplicated) With at Least One Service 14
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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 8 7.500000 2059.0000 1681.5400
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
10 9.500000 1146.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18 17.000000 3205.5000 1681.5400