CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Payclass Filters:OTHER
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 4 2.50 92.50 37.00
Subtotal (Total Children Is Unduplicated) 4 2.50 92.50 37.00
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.50 25.00 50.00
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 3.00 150.00 50.00
Subtotal (Total Children Is Unduplicated) 1 3.50 175.00 50.00
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Total 6.00 267.50 44.58
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Number of Children (Unduplicated) With at Least One Service 5
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Center 01
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
2 3.50 175.00 0.00
Other 0 0.00 0.00 0.00
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Total 2 3.50 175.00 0.00
Center 53
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 6.00 267.50 0.00
Other 0 0.00 0.00 0.00
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Total 7 6.00 267.50 0.00