CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
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 66 83.750000 3052.5000 36.4478
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 77 182.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 90 392.250000 14365.2500 36.6227
Subtotal (Total Children Is Unduplicated) 91 658.500000 17417.7500 26.4506
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 22.000000 1650.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 66.000000 3607.5000 54.6591
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 99.500000 7462.5000 75.0000
Subtotal (Total Children Is Unduplicated) 63 204.000000 13801.5000 67.6544
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.000000 350.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 65 132.000000 1311.0000 9.9318
TRAV-TRAVS-Travel by mile 22 674.000000 300.0100 0.4451
Subtotal (Total Children Is Unduplicated) 65 813.000000 1961.0100 2.4121
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Total 1675.500000 33180.2600 19.8032
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Number of Children (Unduplicated) With at Least One Service 91
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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 149 166.750000 7144.5000 0.0000
P 151 162.250000 7658.5000 7658.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 40 489.500000 679.4700 679.4700
T 183 186.750000 2836.3600 2836.3600
544 670.250000 14861.4300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1067 1675.500000 33180.2600 11174.3300