CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 46.00 1150.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 36 551.00 13775.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 19 43.50 2952.78 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 61.50 4174.62 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
Subtotal (Total Children Is Unduplicated) 39 704.50 22159.00 31.45
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Total 704.50 22159.00 31.45
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Number of Children (Unduplicated) With at Least One Service 39
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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 1 2.50 169.70 169.70
T 0 0.00 0.00 0.00
134 702.00 21989.30 0.00
Other 0 0.00 0.00 0.00
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Total 135 704.50 22159.00 169.70