CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2012 ending 06/30/2012 Date of Report:08/16/2012 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 21 40.250000 1489.2500 37.0000
Subtotal (Total Children Is Unduplicated) 21 40.250000 1489.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
Subtotal (Total Children Is Unduplicated) 5 19.500000 1316.2500 67.5000
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 20.000000 10.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1 20.000000 10.0000 0.5000
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Total 79.750000 2815.5000 35.3041
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Number of Children (Unduplicated) With at Least One Service 27
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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
3 4.500000 166.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3 4.500000 166.5000 0.0000
Center 52
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 6 11.500000 755.2500 0.0000
T 0 0.000000 0.0000 0.0000
1 20.000000 10.0000 0.0000
Other 2 4.000000 261.0000 0.0000
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Total 9 35.500000 1026.2500 0.0000
Center 55
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
48 39.750000 1622.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 48 39.750000 1622.7500 0.0000