CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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 1576 986.750000 36509.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 849 666.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2127 5277.000000 195227.2500 36.9959
Subtotal (Total Children Is Unduplicated) 2292 6929.750000 231737.0000 33.4409
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 185 288.500000 21637.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 122 205.000000 15375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 280 455.000000 25252.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 100 156.500000 11737.5000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 83.2900 83.2900
Subtotal (Total Children Is Unduplicated) 352 1128.000000 75648.0400 67.0639
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EI Services,Class #03
INTR-T1013-INTERPRETER 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 100.0000 50.0000
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Total 8059.750000 307485.0400 38.1507
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Number of Children (Unduplicated) With at Least One Service 2292
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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
12711 8059.750000 307485.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 12711 8059.750000 307485.0400 0.0000