CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 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 8 2.25 83.25 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 14 14.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 15 11.50 425.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 59 118.50 4384.50 37.00
Subtotal (Total Children Is Unduplicated) 70 146.25 4893.25 33.46
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
Subtotal (Total Children Is Unduplicated) 1 1.00 50.00 50.00
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.50 175.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 2.00 135.76 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 4.50 196.10 43.58
SPL-92508-GROUP SPL SESSION PER CHILD 8 120.00 1584.00 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 32.00 16.00 0.50
Subtotal (Total Children Is Unduplicated) 16 162.00 2106.86 13.01
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Total 309.25 7050.11 22.80
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Number of Children (Unduplicated) With at Least One Service 86
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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
289 309.25 7050.11 0.00
Other 0 0.00 0.00 0.00
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Total 289 309.25 7050.11 0.00