CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 5 5.00 250.00 50.00
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 2 2.00 145.56 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 3 3.00 150.45 50.15
Subtotal (Total Children Is Unduplicated) 5 10.00 546.01 54.60
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Total 10.00 546.01 54.60
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Number of Children (Unduplicated) With at Least One Service 5
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Center 05
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
10 10.00 546.01 0.00
Other 0 0.00 0.00 0.00
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Total 10 10.00 546.01 0.00