CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 1.250000 46.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 5.000000 185.0000 37.0000
Subtotal (Total Children Is Unduplicated) 2 7.750000 231.2500 29.8387
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Screening, Eval, and Assessment,Class #02
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 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 1 4.000000 261.0000 65.2500
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EI Services,Class #03
TRAV-TRAVS-Travel by mile 1 39.000000 17.3600 0.4451
Subtotal (Total Children Is Unduplicated) 1 39.000000 17.3600 0.4451
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Total 50.750000 509.6100 10.0416
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Number of Children (Unduplicated) With at Least One Service 2
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Center 02
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
0 0.000000 0.0000 0.0000
Other 18 50.750000 509.6100 0.0000
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Total 18 50.750000 509.6100 0.0000