CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 85 90.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 186 682.500000 25252.5000 37.0000
Subtotal (Total Children Is Unduplicated) 186 773.000000 25252.5000 32.6682
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 97 162.000000 12150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 55.500000 4162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 28.000000 2100.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 107 187.000000 10378.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 28.000000 2100.0000 75.0000
Subtotal (Total Children Is Unduplicated) 138 472.000000 31714.5000 67.1917
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Total 1245.000000 56967.0000 45.7566
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Number of Children (Unduplicated) With at Least One Service 190
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Center 10
Flag Claims Units Chgs Paid
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R 4 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 611 650.500000 30530.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 14 13.000000 481.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
506 578.250000 25835.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1135 1245.000000 56967.0000 0.0000