CMS/EIP Fiscal Report Center: 55
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 109 111.750000 4134.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 19 15.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 33 106.500000 3940.5000 37.0000
Subtotal (Total Children Is Unduplicated) 114 233.250000 8075.2500 34.6206
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 6.000000 300.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 24.019333 1801.4500 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
Subtotal (Total Children Is Unduplicated) 19 58.019333 4045.4500 69.7259
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 16.000000 160.0000 10.0000
Subtotal (Total Children Is Unduplicated) 2 16.000000 160.0000 10.0000
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Total 307.269333 12280.7000 39.9672
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Number of Children (Unduplicated) With at Least One Service 116
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Center 55
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 32 48.000000 2354.0000 2354.0000
D 8 16.000000 1200.0000 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
345 243.269333 8726.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 385 307.269333 12280.7000 2354.0000