CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 2 3.000000 225.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 22.000000 2678.1600 121.7345
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 769.9900 192.4975
Subtotal (Total Children Is Unduplicated) 23 29.000000 3673.1500 126.6603
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Total 29.000000 3673.1500 126.6603
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Number of Children (Unduplicated) With at Least One Service 23
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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 11 11.000000 2094.1500 2094.1500
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
16 18.000000 1579.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 27 29.000000 3673.1500 2094.1500