CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 68 30.750000 1137.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 61 58.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 73 212.750000 7871.7500 37.0000
Subtotal (Total Children Is Unduplicated) 123 301.500000 9009.5000 29.8823
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 2 3.500000 262.5000 75.0000
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EI Services,Class #03
INTR-T1013-INTERPRETER 2 16.500000 712.5000 43.1818
Subtotal (Total Children Is Unduplicated) 2 16.500000 712.5000 43.1818
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Total 321.500000 9984.5000 31.0560
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Number of Children (Unduplicated) With at Least One Service 125
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Center 03
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
428 321.500000 9984.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 428 321.500000 9984.5000 0.0000