CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 20.000000 1084.5000 54.2250
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 24.000000 2542.1800 105.9242
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 504.9000 168.3000
Subtotal (Total Children Is Unduplicated) 28 64.000000 5387.0800 84.1731
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Total 64.000000 5387.0800 84.1731
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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 7 7.000000 1289.1700 1289.1700
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
62 57.000000 4097.9100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 69 64.000000 5387.0800 1289.1700