CMS/EIP Fiscal Report Center: 57
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 10 4.250000 157.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 2.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 27 127.250000 4708.2500 37.0000
Subtotal (Total Children Is Unduplicated) 32 134.250000 4865.5000 36.2421
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 16.500000 915.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 7.000000 525.0000 75.0000
Subtotal (Total Children Is Unduplicated) 19 40.500000 2696.2500 66.5741
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 6.000000 60.0000 10.0000
TRAV-TRAVS-Travel by mile 1 145.000000 64.5300 0.4450
Subtotal (Total Children Is Unduplicated) 3 151.000000 124.5300 0.8247
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Total 325.750000 7686.2800 23.5956
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Number of Children (Unduplicated) With at Least One Service 35
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Center 57
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 4 4.000000 40.0000 40.0000
H 0 0.000000 0.0000 0.0000
T 5 151.000000 345.5300 345.5300
150 170.750000 7300.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 159 325.750000 7686.2800 385.5300