CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/16/2009 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 34 12.75 471.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 15 15.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 12.00 444.00 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 5 12.25 453.25 37.00
Subtotal (Total Children Is Unduplicated) 48 52.00 1369.00 26.33
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 6.50 325.00 50.00
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 165.00 82.50 0.50
Subtotal (Total Children Is Unduplicated) 1 171.50 407.50 2.38
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Total 223.50 1776.50 7.95
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Number of Children (Unduplicated) With at Least One Service 48
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Center 05
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 6 171.50 407.50 407.50
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
100 52.00 1369.00 0.00
Other 0 0.00 0.00 0.00
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Total 106 223.50 1776.50 407.50