CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2008 ending 12/31/2008 Date of Report:02/17/2009 Page: 1
Payclass Filters:TPIN
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 2 3.25 120.25 37.00
Subtotal (Total Children Is Unduplicated) 2 3.25 120.25 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
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.50 138.75 55.50
Subtotal (Total Children Is Unduplicated) 3 3.50 213.75 61.07
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Total 6.75 334.00 49.48
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Number of Children (Unduplicated) With at Least One Service 4
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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 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
7 6.75 334.00 0.00
Other 0 0.00 0.00 0.00
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Total 7 6.75 334.00 0.00