CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Agency Filter:EXT
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 3 39.00 2647.32 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 19.00 1289.72 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 19.50 1323.66 67.88
Subtotal (Total Children Is Unduplicated) 4 77.50 5260.70 67.88
----------------------------------------------------------------------------------------------------------------
Total 77.50 5260.70 67.88
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 4
----------------------------------------------------------------------------------------------------------------
Center 09
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 1 5.00 339.40 339.40
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
20 72.50 4921.30 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 21 77.50 5260.70 339.40