CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 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
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 5 1.50 55.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 5.25 194.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 35.50 1313.50 37.00
Subtotal (Total Children Is Unduplicated) 36 46.25 1563.25 33.80
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.50 175.00 50.00
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 1.00 67.88 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 10.00 5.00 0.50
Subtotal (Total Children Is Unduplicated) 5 15.50 302.20 19.50
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Total 61.75 1865.45 30.21
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Number of Children (Unduplicated) With at Least One Service 41
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Center 06
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
79 61.75 1865.45 0.00
Other 0 0.00 0.00 0.00
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Total 79 61.75 1865.45 0.00