CMS/EIP Fiscal Report Center: 54
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 32 19.750000 730.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 144 155.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 36 127.750000 4699.0000 36.7828
Subtotal (Total Children Is Unduplicated) 153 303.000000 5429.7500 17.9200
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 17.000000 1275.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.000000 610.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 17 34.500000 2373.0000 68.7826
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.500000 75.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 111 128.250000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 138 277.000000 2770.0000 10.0000
TRAV-TRAVS-Travel by mile 81 2116.000000 941.8600 0.4451
Subtotal (Total Children Is Unduplicated) 138 2523.750000 3811.8600 1.5104
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Total 2861.250000 11614.6100 4.0593
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Number of Children (Unduplicated) With at Least One Service 156
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Center 54
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 77 778.500000 977.0600 977.0600
T 87 754.500000 1281.6700 1271.6700
796 1328.250000 9355.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 960 2861.250000 11614.6100 2248.7300