CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:LEA
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 18 78.00 3900.00 50.00
Subtotal (Total Children Is Unduplicated) 18 78.00 3900.00 50.00
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Total 78.00 3900.00 50.00
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Number of Children (Unduplicated) With at Least One Service 18
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Center 01
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
41 78.00 3900.00 0.00
Other 0 0.00 0.00 0.00
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Total 41 78.00 3900.00 0.00