CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
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 21 9.750000 360.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 31 40.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 62 235.000000 8695.0000 37.0000
Subtotal (Total Children Is Unduplicated) 62 284.750000 9055.7500 31.8025
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 33.500000 2512.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 19.000000 1425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 16.000000 888.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 22.500000 1687.5000 75.0000
Subtotal (Total Children Is Unduplicated) 43 95.000000 6764.2500 71.2026
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 15 26.000000 260.0000 10.0000
TRAV-TRAVS-Travel by mile 24 542.000000 241.2400 0.4451
Subtotal (Total Children Is Unduplicated) 25 568.000000 501.2400 0.8825
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Total 947.750000 16321.2400 17.2210
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Number of Children (Unduplicated) With at Least One Service 62
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Center 05
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 178 159.500000 7497.5000 0.0000
P 96 617.500000 3852.9900 3852.9900
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 0 0.000000 0.0000 0.0000
227 170.750000 4970.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 501 947.750000 16321.2400 3852.9900