CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 17 25.750000 952.7500 37.0000
Subtotal (Total Children Is Unduplicated) 17 25.750000 952.7500 37.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 4.000000 200.0000 50.0000
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Total 29.750000 1152.7500 38.7479
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Number of Children (Unduplicated) With at Least One Service 20
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Center 09
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
32 29.750000 1152.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 32 29.750000 1152.7500 0.0000