CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 1391 1030.750000 38137.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 903 793.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 727 2174.000000 80438.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1685 3998.250000 118575.7500 29.6569
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 19.000000 1425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 12.000000 900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 18.500000 1387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 33.500000 1859.2500 55.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 151.4400 75.7200
Subtotal (Total Children Is Unduplicated) 28 85.000000 5723.1900 67.3316
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Total 4083.250000 124298.9400 30.4412
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Number of Children (Unduplicated) With at Least One Service 1685
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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
7153 4083.250000 124298.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7153 4083.250000 124298.9400 0.0000