CMS/EIP Fiscal Report Center: 52
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 38 18.750000 693.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 31 19.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 44 188.250000 6919.0000 36.7543
Subtotal (Total Children Is Unduplicated) 73 226.000000 7612.7500 33.6847
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 646.9600 68.1011
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 250.0000 62.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
Subtotal (Total Children Is Unduplicated) 7 23.500000 1529.9600 65.1047
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 5.000000 50.0000 10.0000
TRAV-TRAVS-Travel by mile 45 1542.000000 686.4600 0.4452
Subtotal (Total Children Is Unduplicated) 45 1547.500000 736.4600 0.4759
-----------------------------------------------------------------------------------------------------------------------
Total 1797.000000 9879.1700 5.4976
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 84
-----------------------------------------------------------------------------------------------------------------------
Center 52
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 91 1563.500000 1923.4200 1823.4200
293 233.500000 7955.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 384 1797.000000 9879.1700 1823.4200