CMS/EIP Fiscal Report Center: 51
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 4 1.50 55.50 37.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 4.50 166.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 13.75 508.75 37.00
Subtotal (Total Children Is Unduplicated) 10 19.75 730.75 37.00
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.00 350.00 50.00
PHY-97110-PT SESSION BY LICENSED PT 1 6.50 441.22 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 21.00 1425.48 67.88
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 6 1927.00 913.50 0.47
Subtotal (Total Children Is Unduplicated) 6 1961.50 3130.20 1.60
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Total 1981.25 3860.95 1.95
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Number of Children (Unduplicated) With at Least One Service 11
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Center 51
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 34 1961.50 3130.20 3130.20
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
39 19.75 730.75 0.00
Other 0 0.00 0.00 0.00
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Total 73 1981.25 3860.95 3130.20