CMS/EIP Fiscal Report Center: 55
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 143 246.500000 9120.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 15.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 24 71.500000 2645.5000 37.0000
Subtotal (Total Children Is Unduplicated) 149 333.750000 11766.0000 35.2539
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.176237 688.2202 75.0003
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.359600 401.9700 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
Subtotal (Total Children Is Unduplicated) 11 28.035837 1995.4402 71.1746
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
INTR-T1013-INTERPRETER 1 2.000000 114.0000 57.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
Subtotal (Total Children Is Unduplicated) 2 3.000000 124.0000 41.3333
-----------------------------------------------------------------------------------------------------------------------
Total 364.785837 13885.4402 38.0646
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 150
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 15 24.704737 1644.6102 1644.6100
D 2 1.000000 37.0000 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
498 339.081100 12203.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 515 364.785837 13885.4402 1644.6100