CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
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 4 2.500000 92.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 9.250000 342.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 46 170.500000 6308.5000 37.0000
Subtotal (Total Children Is Unduplicated) 46 182.250000 6743.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 41.000000 3075.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 65.500000 3635.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 30.000000 2250.0000 75.0000
Subtotal (Total Children Is Unduplicated) 52 142.000000 9314.2500 65.5933
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 189.000000 132.3000 0.7000
Subtotal (Total Children Is Unduplicated) 3 189.000000 132.3000 0.7000
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Total 513.250000 16189.8000 31.5437
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Number of Children (Unduplicated) With at Least One Service 56
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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 38 44.750000 2193.5000 0.0000
P 47 73.500000 3810.0000 3810.0000
D 2 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3 189.000000 132.3000 132.3000
162 204.000000 9904.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 252 513.250000 16189.8000 3942.3000