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
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 2 1.500000 318.9400 212.6267
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 6.500000 487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 29.500000 1637.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 58.500000 5815.3600 99.4079
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3637.3600 279.7969
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 1253.9300 417.9767
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 111.9700 55.9850
Subtotal (Total Children Is Unduplicated) 54 122.000000 13862.3100 113.6255
-----------------------------------------------------------------------------------------------------------------------
Total 122.000000 13862.3100 113.6255
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 54
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 16 17.000000 3460.1400 3460.1400
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
112 105.000000 10402.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 128 122.000000 13862.3100 3460.1400