CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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 37 16.500000 610.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 51 52.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 47 190.000000 7030.0000 37.0000
Subtotal (Total Children Is Unduplicated) 86 258.500000 7640.5000 29.5571
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
Subtotal (Total Children Is Unduplicated) 8 16.000000 1044.0000 65.2500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 5.000000 29.4600 5.8920
TRAV-TRAVS-Travel by mile 8 224.000000 99.7100 0.4451
Subtotal (Total Children Is Unduplicated) 11 230.000000 179.1700 0.7790
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Total 504.500000 8863.6700 17.5692
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Number of Children (Unduplicated) With at Least One Service 88
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Center 01
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
337 258.500000 7640.5000 0.0000
Other 26 246.000000 1223.1700 0.0000
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Total 363 504.500000 8863.6700 0.0000