CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2015 ending 06/30/2016 Date of Report:08/06/2016 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 189 240.750000 8833.7500 36.6926
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 239 706.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 73 319.000000 11803.0000 37.0000
Subtotal (Total Children Is Unduplicated) 248 1266.250000 20636.7500 16.2975
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 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 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 36.190800 1980.8394 54.7332
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 48.844000 3700.8000 75.7678
Subtotal (Total Children Is Unduplicated) 46 98.534800 6694.1394 67.9368
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 4.000000 200.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 8.750000 512.5000 58.5714
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.250000 6.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
INTR-T1013-INTERPRETER 1 4.000000 280.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 233 521.000000 5201.0000 9.9827
TRAV-A0160-*PROV TRAVEL TO NATURAL ENV-BY MIN 10 396.000000 198.0000 0.5000
TRAV-TRAVS-Travel by mile 85 3360.000000 1495.4650 0.4451
Subtotal (Total Children Is Unduplicated) 242 4295.000000 7943.2150 1.8494
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Total 5659.784800 35274.1044 6.2324
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Number of Children (Unduplicated) With at Least One Service 263
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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 220 2223.000000 4589.6750 4589.6750
T 485 2065.000000 7631.5400 7631.5900
1654 1371.784800 23052.8894 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2359 5659.784800 35274.1044 12221.2650