CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 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
CASE-CASE-NON-TCM CASE MANAGEMENT 5 1.50 55.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 17 22.50 832.50 37.00
Subtotal (Total Children Is Unduplicated) 18 28.00 888.00 31.71
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.00 67.88 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 5 100.00 1320.00 13.20
Subtotal (Total Children Is Unduplicated) 6 101.00 1387.88 13.74
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Total 129.00 2275.88 17.64
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Number of Children (Unduplicated) With at Least One Service 24
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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
97 129.00 2275.88 0.00
Other 0 0.00 0.00 0.00
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Total 97 129.00 2275.88 0.00