CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 67.8800 67.8800
Subtotal (Total Children Is Unduplicated) 1 1.000000 67.8800 67.8800
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Total 1.000000 67.8800 67.8800
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Number of Children (Unduplicated) With at Least One Service 1
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Center 57
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 1.000000 67.8800 67.8800
Other 0 0.000000 0.0000 0.0000
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Total 1 1.000000 67.8800 67.8800