CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2009 ending 12/31/2009 Date of Report:02/15/2010 Page: 1
Payclass Filters:MED
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 13 71.25 2636.25 37.00
Subtotal (Total Children Is Unduplicated) 13 71.25 2636.25 37.00
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.00 300.00 75.00
Subtotal (Total Children Is Unduplicated) 4 4.00 300.00 75.00
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Total 75.25 2936.25 39.02
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Number of Children (Unduplicated) With at Least One Service 13
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Center 05
Flag Claims Units Chgs Paid
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R 16 13.75 508.75 0.00
U 0 0.00 0.00 0.00
B 28 18.75 693.75 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
78 42.75 1733.75 0.00
Other 0 0.00 0.00 0.00
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Total 122 75.25 2936.25 0.00