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
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 8 7.000000 1177.5000 168.2143
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 48.500000 7142.5000 147.2680
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3784.0000 291.0769
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 507.0000 507.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 280.0000 280.0000
Subtotal (Total Children Is Unduplicated) 63 70.500000 12891.0000 182.8511
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Total 70.500000 12891.0000 182.8511
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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 28 24.500000 7211.5000 5429.2100
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
50 46.000000 5679.5000 43.1800
Other 0 0.000000 0.0000 0.0000
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Total 78 70.500000 12891.0000 5472.3900