CMS/EIP Fiscal Report Center: 54
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 36 24.500000 888.0000 36.2449
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 96 184.250000 27.7500 0.1506
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 93.250000 3450.2500 37.0000
Subtotal (Total Children Is Unduplicated) 103 302.000000 4366.0000 14.4570
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 20.000000 1110.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 17 36.500000 2347.5000 64.3151
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 81 142.000000 1420.0000 10.0000
TRAV-TRAVS-Travel by mile 42 567.800000 252.7700 0.4452
Subtotal (Total Children Is Unduplicated) 81 709.800000 1672.7700 2.3567
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Total 1048.300000 8386.2700 7.9999
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Number of Children (Unduplicated) With at Least One Service 103
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Center 54
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 1 2.500000 92.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 161 273.950000 2035.2700 2035.2700
T 190 462.600000 3024.4500 3024.4500
236 309.250000 3234.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 588 1048.300000 8386.2700 5059.7200