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
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 66 83.750000 3052.5000 36.4478
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 77 182.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 24 77.250000 2858.2500 37.0000
Subtotal (Total Children Is Unduplicated) 86 343.500000 5910.7500 17.2074
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.500000 1687.5000 75.0000
Subtotal (Total Children Is Unduplicated) 15 30.500000 2209.5000 72.4426
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EI Services,Class #03
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) 65 806.000000 1611.0100 1.9988
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Total 1180.000000 9731.2600 8.2468
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Number of Children (Unduplicated) With at Least One Service 86
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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 0 0.000000 0.0000 0.0000
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
422 503.750000 6215.4300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 645 1180.000000 9731.2600 3515.8300