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:Program Patients
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 3 3.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.25 46.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 5 11.00 407.00 37.00
Subtotal (Total Children Is Unduplicated) 5 15.25 453.25 29.72
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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 50.25 655.01 13.04
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Number of Children (Unduplicated) With at Least One Service 7
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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
23 50.25 655.01 0.00
Other 0 0.00 0.00 0.00
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Total 23 50.25 655.01 0.00