CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:LEA
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 2 2.500000 125.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 2.500000 125.0000 50.0000
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EI Services,Class #03
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 8 28.500000 1425.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 7 11.000000 746.6800 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 108.6400 54.3200
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 18 44.500000 2430.3200 54.6139
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Total 47.000000 2555.3200 54.3685
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Number of Children (Unduplicated) With at Least One Service 19
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Center 10
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
20 47.000000 2555.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 20 47.000000 2555.3200 0.0000