CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 6.000000 222.0000 37.0000
Subtotal (Total Children Is Unduplicated) 4 6.000000 222.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 150.0000 75.0000
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 38.000000 19.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1 38.000000 19.0000 0.5000
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Total 46.000000 391.0000 8.5000
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Number of Children (Unduplicated) With at Least One Service 6
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Center 57
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
9 46.000000 391.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9 46.000000 391.0000 0.0000