CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2012 ending 03/31/2012 Date of Report:05/15/2012 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 5.750000 212.7500 37.0000
Subtotal (Total Children Is Unduplicated) 3 5.750000 212.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
Subtotal (Total Children Is Unduplicated) 4 11.000000 717.7500 65.2500
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 53.000000 26.5000 0.5000
Subtotal (Total Children Is Unduplicated) 3 53.000000 26.5000 0.5000
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Total 69.750000 957.0000 13.7204
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Number of Children (Unduplicated) With at Least One Service 10
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Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
5 5.750000 212.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5 5.750000 212.7500 0.0000
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 5 9.000000 606.7500 0.0000
T 0 0.000000 0.0000 0.0000
3 53.000000 26.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8 62.000000 633.2500 0.0000
Center 57
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 1 2.000000 111.0000 111.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1 2.000000 111.0000 111.0000