CMS/EIP Fiscal Report Center: 52
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:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 3 3.000000 111.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.750000 27.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 6.750000 249.7500 37.0000
Subtotal (Total Children Is Unduplicated) 4 10.500000 388.5000 37.0000
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 34.000000 17.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1 34.000000 17.0000 0.5000
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Total 44.500000 405.5000 9.1124
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Number of Children (Unduplicated) With at Least One Service 4
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Center 52
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
18 44.500000 405.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18 44.500000 405.5000 0.0000