CMS/EIP Fiscal Report Center: 10
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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 63 57.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 61 216.500000 8010.5000 37.0000
Subtotal (Total Children Is Unduplicated) 95 274.000000 8010.5000 29.2354
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
Subtotal (Total Children Is Unduplicated) 9 31.500000 2148.0000 68.1905
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EI Services,Class #03
CONIF-CONIF-CONSULT, FACE TO FACE 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 12.000000 120.0000 10.0000
Subtotal (Total Children Is Unduplicated) 1 13.000000 170.0000 13.0769
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Total 318.500000 10328.5000 32.4286
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Number of Children (Unduplicated) With at Least One Service 104
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Center 10
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 5 13.000000 170.0000 170.0000
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
334 305.500000 10158.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 339 318.500000 10328.5000 170.0000