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
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 4 2.500000 92.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 9.250000 342.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 30 110.750000 4097.7500 37.0000
Subtotal (Total Children Is Unduplicated) 33 122.500000 4532.5000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 23.500000 1762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 35.000000 1942.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 14.500000 1087.5000 75.0000
Subtotal (Total Children Is Unduplicated) 26 73.000000 4792.5000 65.6507
-----------------------------------------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------------------------------------
Total 384.500000 9457.3000 24.5964
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 38
-----------------------------------------------------------------------------------------------------------------------
Center 57
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 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
154 193.500000 9175.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 159 384.500000 9457.3000 132.3000