CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 19 8.750000 323.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 31 36.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 44.250000 1637.2500 37.0000
Subtotal (Total Children Is Unduplicated) 35 89.750000 1961.0000 21.8496
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 8.500000 471.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
Subtotal (Total Children Is Unduplicated) 10 21.000000 1409.2500 67.1071
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EI Services,Class #03
INTR-T1013-INTERPRETER 1 1.500000 75.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 20 31.000000 310.0000 10.0000
TRAV-TRAVS-Travel by mile 32 751.000000 334.2600 0.4451
Subtotal (Total Children Is Unduplicated) 32 783.500000 719.2600 0.9180
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Total 894.250000 4089.5100 4.5731
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Number of Children (Unduplicated) With at Least One Service 41
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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 85 804.500000 2128.5100 2128.5100
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
135 89.750000 1961.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 220 894.250000 4089.5100 2128.5100