CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Not Part C
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 6 6.00 1110.00 185.00
Subtotal (Total Children Is Unduplicated) 6 6.00 1110.00 185.00
----------------------------------------------------------------------------------------------------------------
Total 6.00 1110.00 185.00
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 6
----------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
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
6 6.00 1110.00 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6 6.00 1110.00 0.00