CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1365 1516.500000 56110.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 668 544.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 495 1155.000000 42735.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1458 3215.500000 98845.5000 30.7403
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 18.500000 1387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.500000 693.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
Subtotal (Total Children Is Unduplicated) 17 50.000000 3434.2700 68.6854
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Total 3265.500000 102279.7700 31.3213
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Number of Children (Unduplicated) With at Least One Service 1458
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Center 06
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 0 0.000000 0.0000 0.0000
6514 3265.500000 102279.7700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6514 3265.500000 102279.7700 0.0000