CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2010 ending 09/30/2010 Date of Report:11/17/2010 Page: 1
Payclass Filters:OTHER
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
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 370.0000 185.0000
Subtotal (Total Children Is Unduplicated) 2 2.000000 370.0000 185.0000
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Total 2.000000 370.0000 185.0000
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Number of Children (Unduplicated) With at Least One Service 2
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Center 04
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 2.000000 370.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2 2.000000 370.0000 0.0000