CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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 84 2722.00 68050.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 48 1915.00 47875.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 312.00 15600.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 17 112.50 7636.50 67.88
PHY-97110-PT SESSION BY LICENSED PT 48 173.50 11777.18 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 65 221.00 15001.48 67.88
Subtotal (Total Children Is Unduplicated) 156 5456.00 165940.16 30.41
----------------------------------------------------------------------------------------------------------------
Total 5456.00 165940.16 30.41
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 156
----------------------------------------------------------------------------------------------------------------
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
648 5456.00 165940.16 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 648 5456.00 165940.16 0.00