CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 27.000000 2189.7000 81.1000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 912.0000 304.0000
Subtotal (Total Children Is Unduplicated) 27 30.000000 3101.7000 103.3900
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 1.500000 107.1600 71.4400
Subtotal (Total Children Is Unduplicated) 1 1.500000 107.1600 71.4400
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Total 31.500000 3208.8600 101.8686
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Number of Children (Unduplicated) With at Least One Service 28
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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 1 1.000000 239.7000 239.7000
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
29 29.000000 2862.0000 0.0000
Other 1 1.500000 107.1600 0.0000
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Total 31 31.500000 3208.8600 239.7000