CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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 46 48.500000 1794.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 59 208.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 19 65.500000 2423.5000 37.0000
Subtotal (Total Children Is Unduplicated) 62 322.250000 4218.0000 13.0892
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
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 2 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.500000 262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 5 8.500000 559.5000 65.8235
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 54 102.000000 1020.0000 10.0000
TRAV-TRAVS-Travel by mile 14 207.000000 92.1600 0.4452
Subtotal (Total Children Is Unduplicated) 54 309.000000 1112.1600 3.5992
-----------------------------------------------------------------------------------------------------------------------
Total 639.750000 5889.6600 9.2062
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 62
-----------------------------------------------------------------------------------------------------------------------
Center 53
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 11 46.000000 87.3700 87.3700
T 0 0.000000 0.0000 0.0000
441 592.750000 5792.2900 0.0000
Other 1 1.000000 10.0000 0.0000
---------------------------------------------------------
Total 453 639.750000 5889.6600 87.3700