CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
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 3 2.000000 74.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 39 136.750000 5059.7500 37.0000
Subtotal (Total Children Is Unduplicated) 39 138.750000 5133.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 15.500000 1162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 41.000000 2275.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 24.500000 1837.5000 75.0000
Subtotal (Total Children Is Unduplicated) 40 84.000000 5500.5000 65.4821
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 10.000000 100.0000 10.0000
TRAV-TRAVS-Travel by mile 1 145.000000 64.5300 0.4450
Subtotal (Total Children Is Unduplicated) 5 155.000000 164.5300 1.0615
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Total 377.750000 10798.7800 28.5871
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Number of Children (Unduplicated) With at Least One Service 46
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Center 57
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 63 80.250000 3741.2500 0.0000
P 5 6.500000 381.7500 381.7500
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 15 163.000000 686.5300 686.5300
108 128.000000 5989.2500 783.0000
Other 0 0.000000 0.0000 0.0000
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Total 191 377.750000 10798.7800 1851.2800