CMS/EIP Fiscal Report Center: 53
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 1 1.000000 37.0000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.500000 92.5000 37.0000
Subtotal (Total Children Is Unduplicated) 2 4.500000 129.5000 28.7778
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 540.000000 270.0000 0.5000
Subtotal (Total Children Is Unduplicated) 3 540.000000 270.0000 0.5000
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Total 544.500000 399.5000 0.7337
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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 1 105.000000 52.5000 52.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 175.000000 87.5000 87.5000
T 6 3.250000 83.2500 83.2500
7 261.250000 176.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16 544.500000 399.5000 223.2500