CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 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 14 8.500000 314.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 42.000000 1554.0000 37.0000
Subtotal (Total Children Is Unduplicated) 25 56.500000 1868.5000 33.0708
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 6 5.500000 275.0000 50.0000
Subtotal (Total Children Is Unduplicated) 6 5.500000 275.0000 50.0000
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 4 4.000000 32.0000 8.0000
Subtotal (Total Children Is Unduplicated) 4 4.000000 32.0000 8.0000
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Total 66.000000 2175.5000 32.9621
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Number of Children (Unduplicated) With at Least One Service 25
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Center 04
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
113 66.000000 2175.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 113 66.000000 2175.5000 0.0000