CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:LEA
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.75 37.50 50.00
Subtotal (Total Children Is Unduplicated) 1 0.75 37.50 50.00
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 12.00 600.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 7.00 350.00 50.00
HERN-EIIF_NM-EI HEARING SERVICES AFTER SHINE NONMED 3 7.25 362.50 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 7 11.25 562.50 50.00
OCCT-97530-OT SESSION BY LICENSED OT 10 50.00 3394.00 67.88
PHY-97110-PT SESSION BY LICENSED PT 10 41.25 2800.05 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 11 10.50 525.00 50.00
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 17 70.50 3525.00 50.00
Subtotal (Total Children Is Unduplicated) 36 209.75 12119.05 57.78
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Total 210.50 12156.55 57.75
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Number of Children (Unduplicated) With at Least One Service 36
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Center 10
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
97 210.50 12156.55 0.00
Other 0 0.00 0.00 0.00
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Total 97 210.50 12156.55 0.00