CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 Page: 1
Agency Filter:EXT
Payclass Filters:TPIN
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
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 1 1.00 50.00 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 12.00 400.00 33.33
OCCT-97530-OT SESSION BY LICENSED OT 1 3.50 237.58 67.88
PHY-97110-PT SESSION BY LICENSED PT 2 4.50 305.46 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.00 203.64 67.88
Subtotal (Total Children Is Unduplicated) 4 24.00 1196.68 49.86
----------------------------------------------------------------------------------------------------------------
Total 24.00 1196.68 49.86
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 4
----------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
-------------------------------------------------
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
25 24.00 1196.68 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 25 24.00 1196.68 0.00