CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 63 59.250000 2192.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 43 65.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 24.250000 897.2500 37.0000
Subtotal (Total Children Is Unduplicated) 64 149.250000 3089.5000 20.7002
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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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 10 37.000000 2570.2500 69.4662
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 3.000000 30.0000 10.0000
TRAV-TRAVS-Travel by mile 37 1569.000000 698.3100 0.4451
Subtotal (Total Children Is Unduplicated) 38 1572.000000 728.3100 0.4633
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Total 1758.250000 6388.0600 3.6332
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Number of Children (Unduplicated) With at Least One Service 66
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Center 02
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 0 0.000000 0.0000 0.0000
T 56 1194.000000 2595.4100 2595.4100
2 158.000000 70.3100 0.0000
Other 256 406.250000 3722.3400 0.0000
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Total 314 1758.250000 6388.0600 2595.4100