CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
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 23 19.000000 703.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 22 16.000000 592.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 56 209.000000 7733.0000 37.0000
Subtotal (Total Children Is Unduplicated) 56 244.000000 9028.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 31.500000 2362.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 50.500000 2802.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 28.500000 2137.5000 75.0000
Subtotal (Total Children Is Unduplicated) 43 115.500000 7648.5000 66.2208
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 1 4.000000 40.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 2 188.000000 131.6000 0.7000
Subtotal (Total Children Is Unduplicated) 3 196.000000 371.6000 1.8959
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Total 555.500000 17048.1000 30.6896
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Number of Children (Unduplicated) With at Least One Service 56
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Center 57
Flag Claims Units Chgs Paid
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R 2 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 55 59.500000 2927.2500 0.0000
P 77 99.500000 4585.0000 4585.0000
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 5 192.000000 171.6000 171.6000
190 203.000000 9308.7500 200.0000
Other 0 0.000000 0.0000 0.0000
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Total 329 555.500000 17048.1000 4956.6000