CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/17/2009 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 99 4527.00 113175.00 25.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 51 851.00 21275.00 25.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 99.00 4950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 12 49.00 3326.12 67.88
PHY-97110-PT SESSION BY LICENSED PT 31 82.25 5583.13 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 102.25 6940.73 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 9 11.50 151.80 13.20
Subtotal (Total Children Is Unduplicated) 166 5722.00 155401.78 27.16
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Total 5722.00 155401.78 27.16
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Number of Children (Unduplicated) With at Least One Service 166
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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 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
459 5722.00 155401.78 0.00
Other 0 0.00 0.00 0.00
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Total 459 5722.00 155401.78 0.00