CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 33 16.500000 610.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 23 14.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 43 165.000000 5920.0000 35.8788
Subtotal (Total Children Is Unduplicated) 70 196.000000 6530.5000 33.3189
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 2 8.000000 522.0000 65.2500
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 1.500000 0.0000 0.0000
TRAV-TRAVS-Travel by mile 46 1062.000000 472.7400 0.4451
Subtotal (Total Children Is Unduplicated) 47 1063.500000 472.7400 0.4445
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Total 1267.500000 7525.2400 5.9371
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Number of Children (Unduplicated) With at Least One Service 78
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Center 52
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 70 1068.000000 883.7400 842.7400
257 199.500000 6641.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 327 1267.500000 7525.2400 842.7400