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
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 305 146.500000 5420.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 309 294.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 346 910.500000 33688.5000 37.0000
Subtotal (Total Children Is Unduplicated) 607 1351.250000 39109.0000 28.9428
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 4.500000 337.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.000000 525.0000 75.0000
Subtotal (Total Children Is Unduplicated) 10 17.500000 1312.5000 75.0000
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 0.500000 25.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 6.500000 325.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 63.500000 3175.0000 50.0000
INTR-T1013-INTERPRETER 1 11.000000 550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 8 19.000000 190.0000 10.0000
PHY-97110-PT SESSION BY LICENSED PT 4 23.750000 1696.7000 71.4400
TRAV-TRAVS-Travel by mile 10 1068.000000 475.2700 0.4450
Subtotal (Total Children Is Unduplicated) 28 1192.250000 6436.9700 5.3990
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Total 2561.000000 46858.4700 18.2969
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Number of Children (Unduplicated) With at Least One Service 612
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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 0 0.000000 0.0000 0.0000
P 72 1153.250000 4431.4100 4431.4100
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
2453 1407.750000 42427.0600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2525 2561.000000 46858.4700 4431.4100