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
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 85 90.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 63 230.750000 8537.7500 37.0000
Subtotal (Total Children Is Unduplicated) 114 321.250000 8537.7500 26.5767
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 45.500000 3412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 48.000000 2664.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
Subtotal (Total Children Is Unduplicated) 34 121.000000 8139.0000 67.2645
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Total 442.250000 16676.7500 37.7089
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Number of Children (Unduplicated) With at Least One Service 130
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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 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
429 442.250000 16676.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 429 442.250000 16676.7500 0.0000