CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 17 15.500000 1478.2500 95.3710
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 45.000000 4195.2600 93.2280
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3952.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 386.0000 193.0000
Subtotal (Total Children Is Unduplicated) 64 75.500000 10011.5100 132.6028
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Total 75.500000 10011.5100 132.6028
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Number of Children (Unduplicated) With at Least One Service 64
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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 8.500000 1773.5100 1773.5100
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
71 67.000000 8238.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 79 75.500000 10011.5100 1773.5100