CMS/EIP Fiscal Report Center: 10
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
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 16.50 1120.02 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 360.00 180.00 0.50
Subtotal (Total Children Is Unduplicated) 6 377.50 1350.02 3.58
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Total 377.50 1350.02 3.58
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Number of Children (Unduplicated) With at Least One Service 6
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Center 10
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
10 377.50 1350.02 0.00
Other 0 0.00 0.00 0.00
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Total 10 377.50 1350.02 0.00