CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:OTHER
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
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 31.50 1575.00 50.00
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 92.00 2300.00 25.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 14 98.75 4937.50 50.00
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 97.00 4850.00 50.00
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 8 52.00 2600.00 50.00
Subtotal (Total Children Is Unduplicated) 28 371.25 16262.50 43.80
----------------------------------------------------------------------------------------------------------------
Total 371.25 16262.50 43.80
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 28
----------------------------------------------------------------------------------------------------------------
Center 01
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
116 371.25 16262.50 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 116 371.25 16262.50 0.00