CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 0.500000 37.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 24.500000 2225.6800 90.8441
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 2006.4400 250.8050
Subtotal (Total Children Is Unduplicated) 24 33.000000 4269.6200 129.3824
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Total 33.000000 4269.6200 129.3824
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Number of Children (Unduplicated) With at Least One Service 24
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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 870.6200 870.6200
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
26 27.000000 3399.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 32 33.000000 4269.6200 870.6200