CMS/EIP Fiscal Report Center: 53
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
CASE-CASE-NON-TCM CASE MANAGEMENT 34 40.750000 1498.5000 36.7730
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 54 133.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 57 275.250000 10101.0000 36.6975
Subtotal (Total Children Is Unduplicated) 57 449.750000 11599.5000 25.7910
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 53.000000 2941.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 59.000000 4462.5000 75.6356
Subtotal (Total Children Is Unduplicated) 45 140.500000 9366.0000 66.6619
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 45 89.000000 890.0000 10.0000
TRAV-TRAVS-Travel by mile 11 195.000000 86.7900 0.4451
Subtotal (Total Children Is Unduplicated) 45 284.000000 976.7900 3.4394
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Total 874.250000 21942.2900 25.0984
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Number of Children (Unduplicated) With at Least One Service 57
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Center 53
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 4 6.000000 391.5000 0.0000
P 117 144.500000 6572.5000 6572.5000
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 13 106.000000 328.1700 328.1700
545 616.250000 14537.6200 0.0000
Other 1 1.500000 112.5000 0.0000
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Total 680 874.250000 21942.2900 6900.6700