CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:MED
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 16 72.75 2691.75 37.00
Subtotal (Total Children Is Unduplicated) 16 72.75 2691.75 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 1 1.00 75.00 75.00
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Total 73.75 2766.75 37.52
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Number of Children (Unduplicated) With at Least One Service 16
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Center 02
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 70 70.25 2599.25 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
2 3.50 167.50 0.00
Other 0 0.00 0.00 0.00
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Total 72 73.75 2766.75 0.00