CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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 2 5.500000 203.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.500000 55.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 5.500000 203.5000 37.0000
Subtotal (Total Children Is Unduplicated) 2 13.500000 462.5000 34.2593
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Total 13.500000 462.5000 34.2593
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Number of Children (Unduplicated) With at Least One Service 2
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Center 03
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 13.500000 462.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 31 13.500000 462.5000 0.0000