CMS/EIP Fiscal Report Center: 05
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 21 14.250000 527.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 33 36.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 18 82.250000 3043.2500 37.0000
Subtotal (Total Children Is Unduplicated) 38 132.750000 3570.5000 26.8964
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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-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.500000 412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 7 13.000000 955.5000 73.5000
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 2.000000 20.0000 10.0000
TRAV-TRAVS-Travel by mile 11 235.000000 104.5900 0.4451
Subtotal (Total Children Is Unduplicated) 11 237.000000 124.5900 0.5257
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Total 382.750000 4650.5900 12.1505
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Number of Children (Unduplicated) With at Least One Service 40
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Center 05
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 9 135.000000 134.2550 123.1300
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
219 247.750000 4516.3350 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 228 382.750000 4650.5900 123.1300