CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.750000 27.7500 37.0000
Subtotal (Total Children Is Unduplicated) 3 2.750000 27.7500 10.0909
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
Subtotal (Total Children Is Unduplicated) 4 11.000000 737.2500 67.0227
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Total 13.750000 765.0000 55.6364
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Number of Children (Unduplicated) With at Least One Service 7
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Center 09
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 10 13.000000 737.2500 737.2500
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 1 0.750000 27.7500 27.7500
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11 13.750000 765.0000 765.0000