CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 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 2 10.50 712.74 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 5.00 339.40 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.00 135.76 67.88
Subtotal (Total Children Is Unduplicated) 3 17.50 1187.90 67.88
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Total 17.50 1187.90 67.88
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Number of Children (Unduplicated) With at Least One Service 3
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Center 09
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
7 17.50 1187.90 0.00
Other 0 0.00 0.00 0.00
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Total 7 17.50 1187.90 0.00