CMS/EIP Fiscal Report Center: 53
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
CONOP-CONOP-CONSULT, OT, PHONE 1 0.25 6.25 25.00
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.00 25.00 25.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.50 305.46 67.88
Subtotal (Total Children Is Unduplicated) 4 5.75 336.71 58.56
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Total 5.75 336.71 58.56
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Number of Children (Unduplicated) With at Least One Service 4
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Center 53
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
9 5.75 336.71 0.00
Other 0 0.00 0.00 0.00
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Total 9 5.75 336.71 0.00