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: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 45 25.000000 925.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 54 41.500000 1535.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 37 144.750000 5355.7500 37.0000
Subtotal (Total Children Is Unduplicated) 75 211.250000 7816.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 29.000000 1609.5000 55.5000
Subtotal (Total Children Is Unduplicated) 21 56.000000 3595.5000 64.2054
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 45 2531.000000 1265.5000 0.5000
Subtotal (Total Children Is Unduplicated) 45 2531.000000 1265.5000 0.5000
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Total 2798.250000 12677.2500 4.5304
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Number of Children (Unduplicated) With at Least One Service 80
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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 9 216.000000 331.5000 331.5000
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
417 2582.250000 12345.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 426 2798.250000 12677.2500 331.5000