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
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 3 2.000000 74.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 24 80.000000 2960.0000 37.0000
Subtotal (Total Children Is Unduplicated) 24 82.000000 3034.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 8.500000 637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 14.000000 777.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 5.500000 412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 17 30.000000 1977.0000 65.9000
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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 267.000000 5175.5300 19.3840
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Number of Children (Unduplicated) With at Least One Service 29
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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 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 11 155.000000 164.5300 164.5300
98 112.000000 5011.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 109 267.000000 5175.5300 164.5300