CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 14 12.750000 471.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 22 21.500000 795.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 20 87.250000 3228.2500 37.0000
Subtotal (Total Children Is Unduplicated) 31 121.500000 4495.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 1 4.000000 273.5000 68.3750
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EI Services,Class #03
INTR-INTR-INTERPRETER 3 6.000000 351.0000 58.5000
Subtotal (Total Children Is Unduplicated) 3 6.000000 351.0000 58.5000
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Total 131.500000 5120.0000 38.9354
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Number of Children (Unduplicated) With at Least One Service 31
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Center 06
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 3 6.000000 351.0000 351.0000
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
138 125.500000 4769.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 141 131.500000 5120.0000 351.0000