CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/16/2010 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 1 0.25 9.25 37.00
Subtotal (Total Children Is Unduplicated) 1 0.25 9.25 37.00
----------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.00 100.00 50.00
Subtotal (Total Children Is Unduplicated) 1 2.00 100.00 50.00
----------------------------------------------------------------------------------------------------------------
Total 2.25 109.25 48.56
----------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2
----------------------------------------------------------------------------------------------------------------
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 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2 2.25 109.25 0.00
Other 0 0.00 0.00 0.00
-------------------------------------------------
Total 2 2.25 109.25 0.00