CMS/EIP Fiscal Report Center: 57
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 23 19.000000 703.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 22 16.000000 592.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 27 106.000000 3922.0000 37.0000
Subtotal (Total Children Is Unduplicated) 48 141.000000 5217.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 21.000000 1575.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 23.500000 1304.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 11.500000 862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 22 58.000000 3891.7500 67.0991
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EI Services,Class #03
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 1 4.000000 40.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 2 188.000000 131.6000 0.7000
Subtotal (Total Children Is Unduplicated) 3 192.000000 171.6000 0.8938
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Total 391.000000 9280.3500 23.7349
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Number of Children (Unduplicated) With at Least One Service 49
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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 5 192.000000 171.6000 171.6000
188 199.000000 9108.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 193 391.000000 9280.3500 171.6000