CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2011 ending 09/30/2011 Date of Report:11/30/2011 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.750000 64.7500 37.0000
Subtotal (Total Children Is Unduplicated) 3 3.000000 74.0000 24.6667
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 2 225.000000 112.5000 0.5000
Subtotal (Total Children Is Unduplicated) 2 225.000000 112.5000 0.5000
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Total 228.000000 186.5000 0.8180
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Number of Children (Unduplicated) With at Least One Service 3
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Center 53
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 4 122.000000 97.0000 97.0000
4 106.000000 89.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8 228.000000 186.5000 97.0000