CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 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 18 18.00 3330.00 185.00
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.00 105.00 105.00
Subtotal (Total Children Is Unduplicated) 19 19.00 3435.00 180.79
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Total 19.00 3435.00 180.79
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Number of Children (Unduplicated) With at Least One Service 19
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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
19 19.00 3435.00 0.00
Other 0 0.00 0.00 0.00
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Total 19 19.00 3435.00 0.00