CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.50 55.50 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 5.25 194.25 37.00
Subtotal (Total Children Is Unduplicated) 2 6.75 249.75 37.00
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Total 6.75 249.75 37.00
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Number of Children (Unduplicated) With at Least One Service 2
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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
7 6.75 249.75 0.00
Other 0 0.00 0.00 0.00
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Total 7 6.75 249.75 0.00