CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 2 0.750000 27.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 3.750000 138.7500 37.0000
Subtotal (Total Children Is Unduplicated) 2 4.500000 166.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
Subtotal (Total Children Is Unduplicated) 1 3.000000 195.7500 65.2500
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Total 7.500000 362.2500 48.3000
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Number of Children (Unduplicated) With at Least One Service 2
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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
10 7.500000 362.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10 7.500000 362.2500 0.0000