CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.25 46.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 5.50 203.50 37.00
Subtotal (Total Children Is Unduplicated) 3 7.75 249.75 32.23
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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
PHY-97110-PT SESSION BY LICENSED PT 1 2.00 135.76 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 32.00 16.00 0.50
Subtotal (Total Children Is Unduplicated) 2 34.00 151.76 4.46
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Total 42.75 451.51 10.56
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Number of Children (Unduplicated) With at Least One Service 5
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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
14 42.75 451.51 0.00
Other 0 0.00 0.00 0.00
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Total 14 42.75 451.51 0.00