CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 46 1797.00 44925.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 55 2134.00 53350.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 256.00 12800.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 23 146.75 9961.39 67.88
PHY-97110-PT SESSION BY LICENSED PT 57 217.75 14780.87 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 79 280.25 19023.37 67.88
Subtotal (Total Children Is Unduplicated) 127 4831.75 154840.63 32.05
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Total 4831.75 154840.63 32.05
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Number of Children (Unduplicated) With at Least One Service 127
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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
703 4831.75 154840.63 0.00
Other 0 0.00 0.00 0.00
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Total 703 4831.75 154840.63 0.00