CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.00 7215.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.00 840.00 105.00
Subtotal (Total Children Is Unduplicated) 47 47.00 8055.00 171.38
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EI Services,Class #03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 60 2021.00 50525.00 25.00
Subtotal (Total Children Is Unduplicated) 60 2021.00 50525.00 25.00
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Total 2068.00 58580.00 28.33
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Number of Children (Unduplicated) With at Least One Service 107
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Center 04
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
202 2068.00 58580.00 0.00
Other 0 0.00 0.00 0.00
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Total 202 2068.00 58580.00 0.00