CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 3.750000 138.7500 37.0000
Subtotal (Total Children Is Unduplicated) 4 3.750000 138.7500 37.0000
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1 1.000000 48.5000 48.5000
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EI Services,Class #03
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 162.9600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 23.000000 1561.2400 67.8800
Subtotal (Total Children Is Unduplicated) 3 26.000000 1724.2000 66.3154
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Total 30.750000 1911.4500 62.1610
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Number of Children (Unduplicated) With at Least One Service 6
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Center 55
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
38 30.750000 1911.4500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 38 30.750000 1911.4500 0.0000