CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 7.25 362.50 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 8 22.25 1112.50 50.00
PHY-97110-PT SESSION BY LICENSED PT 17 47.00 3190.36 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 7.00 475.16 67.88
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 8 80.00 4000.00 50.00
Subtotal (Total Children Is Unduplicated) 37 163.50 9140.52 55.91
----------------------------------------------------------------------------------------------------------------
Total 163.50 9140.52 55.91
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 37
----------------------------------------------------------------------------------------------------------------
Center 01
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
59 163.50 9140.52 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 59 163.50 9140.52 0.00