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
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 13 16.500000 1237.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 71.000000 6226.8700 87.7024
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 3552.8300 296.0692
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 579.0000 193.0000
Subtotal (Total Children Is Unduplicated) 82 102.500000 11596.2000 113.1337
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Total 102.500000 11596.2000 113.1337
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Number of Children (Unduplicated) With at Least One Service 82
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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 6 6.000000 1485.7000 1485.7000
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
91 96.500000 10110.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 97 102.500000 11596.2000 1485.7000