CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
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 17 17.00 3145.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.00 315.00 105.00
Subtotal (Total Children Is Unduplicated) 20 20.00 3460.00 173.00
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Total 20.00 3460.00 173.00
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Number of Children (Unduplicated) With at Least One Service 20
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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
20 20.00 3460.00 0.00
Other 0 0.00 0.00 0.00
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Total 20 20.00 3460.00 0.00