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
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 34 40.750000 1498.5000 36.7730
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 54 133.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 140.750000 5161.5000 36.6714
Subtotal (Total Children Is Unduplicated) 56 315.250000 6660.0000 21.1261
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 13.000000 975.0000 75.0000
Subtotal (Total Children Is Unduplicated) 12 28.000000 1846.5000 65.9464
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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 627.250000 9483.2900 15.1188
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Number of Children (Unduplicated) With at Least One Service 56
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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 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 13 106.000000 328.1700 328.1700
474 521.250000 9155.1200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 487 627.250000 9483.2900 328.1700