CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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
OCCT-97530-OT SESSION BY LICENSED OT 1 4.50 305.46 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 5.50 373.34 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.00 203.64 67.88
Subtotal (Total Children Is Unduplicated) 1 13.00 882.44 67.88
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Total 13.00 882.44 67.88
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Number of Children (Unduplicated) With at Least One Service 1
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Center 09
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
6 13.00 882.44 0.00
Other 0 0.00 0.00 0.00
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Total 6 13.00 882.44 0.00