CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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 40 19.000000 703.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 48 72.750000 64.7500 0.8900
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 96.500000 3570.5000 37.0000
Subtotal (Total Children Is Unduplicated) 72 188.250000 4338.2500 23.0452
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 698.5400 69.8540
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.000000 423.7900 47.0878
Subtotal (Total Children Is Unduplicated) 10 23.000000 1422.3300 61.8404
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EI Services,Class #03
CONIF-CONIF-CONSULT, FACE TO FACE 1 0.750000 37.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14 25.000000 250.0000 10.0000
TRAV-TRAVS-Travel by mile 42 1151.000000 512.0100 0.4448
Subtotal (Total Children Is Unduplicated) 46 1176.750000 799.5100 0.6794
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Total 1388.000000 6560.0900 4.7263
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Number of Children (Unduplicated) With at Least One Service 84
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Center 52
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 1 2.000000 35.2900 35.2900
H 0 0.000000 0.0000 0.0000
T 86 1127.750000 1822.7900 1773.4500
257 258.250000 4702.0100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 344 1388.000000 6560.0900 1808.7400