CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 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 60 90.750000 3357.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 78 188.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 119.250000 4412.2500 37.0000
Subtotal (Total Children Is Unduplicated) 84 398.500000 7770.0000 19.4981
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
Subtotal (Total Children Is Unduplicated) 7 20.000000 1314.7500 65.7375
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 0.500000 25.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 72 142.000000 1420.0000 10.0000
TRAV-TRAVS-Travel by mile 21 228.000000 101.5100 0.4452
Subtotal (Total Children Is Unduplicated) 72 371.500000 1596.5100 4.2975
-----------------------------------------------------------------------------------------------------------------------
Total 790.000000 10681.2600 13.5206
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 84
-----------------------------------------------------------------------------------------------------------------------
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 0 0.000000 0.0000 0.0000
T 54 261.500000 690.0100 690.0100
639 528.500000 9991.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 693 790.000000 10681.2600 690.0100