CMS/EIP Fiscal Report Center: 52
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
CASE-CASE-NON-TCM CASE MANAGEMENT 17 10.750000 397.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 18.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 112.250000 4153.2500 37.0000
Subtotal (Total Children Is Unduplicated) 48 141.000000 4551.0000 32.2766
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.000000 695.3300 53.4869
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 105.3300 26.3325
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.500000 607.2400 52.8035
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.000000 638.2500 53.1875
Subtotal (Total Children Is Unduplicated) 14 40.500000 2046.1500 50.5222
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 11 23.000000 230.0000 10.0000
TRAV-TRAVS-Travel by mile 39 1261.000000 561.3000 0.4451
Subtotal (Total Children Is Unduplicated) 41 1284.000000 791.3000 0.6163
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Total 1465.500000 7388.4500 5.0416
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Number of Children (Unduplicated) With at Least One Service 60
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Center 52
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 1 2.000000 83.2500 83.2500
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 106 1315.500000 2502.2000 2499.2000
175 148.000000 4803.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 282 1465.500000 7388.4500 2582.4500