CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:LEA
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
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 55 1714.00 42850.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 58 1139.00 28475.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 108.00 5400.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 23 112.75 7653.47 67.88
PHY-97110-PT SESSION BY LICENSED PT 43 136.00 9231.68 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 153.25 10402.61 67.88
Subtotal (Total Children Is Unduplicated) 131 3363.00 104012.76 30.93
----------------------------------------------------------------------------------------------------------------
Total 3363.00 104012.76 30.93
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 131
----------------------------------------------------------------------------------------------------------------
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
464 3363.00 104012.76 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 464 3363.00 104012.76 0.00