CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.25 9.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.75 27.75 37.00
Subtotal (Total Children Is Unduplicated) 1 1.00 37.00 37.00
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EI Services,Class #03
SPL-92508-GROUP SPL SESSION PER CHILD 11 194.00 2560.80 13.20
Subtotal (Total Children Is Unduplicated) 11 194.00 2560.80 13.20
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Total 195.00 2597.80 13.32
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Number of Children (Unduplicated) With at Least One Service 12
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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
99 195.00 2597.80 0.00
Other 0 0.00 0.00 0.00
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Total 99 195.00 2597.80 0.00