CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:TPIN
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 4.25 157.25 37.00
Subtotal (Total Children Is Unduplicated) 2 4.25 157.25 37.00
----------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
Subtotal (Total Children Is Unduplicated) 1 1.00 75.00 75.00
----------------------------------------------------------------------------------------------------------------
Total 5.25 232.25 44.24
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3
----------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
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 1 2.00 74.00 0.00
H 1 1.00 75.00 0.00
T 0 0.00 0.00 0.00
4 2.25 83.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 6 5.25 232.25 0.00