CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:GR
Eligibility Filter:DEI Only
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 2.00 74.00 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.00 37.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 1.00 37.00 37.00
Subtotal (Total Children Is Unduplicated) 7 4.00 148.00 37.00
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 158.00 79.00 0.50
Subtotal (Total Children Is Unduplicated) 2 158.00 79.00 0.50
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Total 162.00 227.00 1.40
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Number of Children (Unduplicated) With at Least One Service 8
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Center 52
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
18 162.00 227.00 0.00
Other 0 0.00 0.00 0.00
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Total 18 162.00 227.00 0.00