CMS/EIP Fiscal Report Center: 57
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 27 23.000000 851.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 15.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 36 223.750000 8278.7500 37.0000
Subtotal (Total Children Is Unduplicated) 60 262.000000 9129.7500 34.8464
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
Subtotal (Total Children Is Unduplicated) 4 9.000000 566.5000 62.9444
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 9.000000 90.0000 10.0000
TRAV-TRAVS-Travel by mile 1 145.000000 64.5300 0.4450
Subtotal (Total Children Is Unduplicated) 3 154.000000 154.5300 1.0034
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Total 425.000000 9850.7800 23.1783
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Number of Children (Unduplicated) With at Least One Service 61
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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 6 154.000000 154.5300 154.5300
194 271.000000 9696.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 200 425.000000 9850.7800 154.5300