CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/15/2012 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 1 0.750000 27.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.000000 74.0000 37.0000
Subtotal (Total Children Is Unduplicated) 2 2.750000 101.7500 37.0000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 295.000000 147.5000 0.5000
Subtotal (Total Children Is Unduplicated) 1 296.000000 197.5000 0.6672
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Total 298.750000 299.2500 1.0017
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Number of Children (Unduplicated) With at Least One Service 2
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Center 53
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 1 55.000000 27.5000 27.5000
T 1 175.000000 87.5000 87.5000
6 68.750000 184.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8 298.750000 299.2500 115.0000