CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 21 7.500000 277.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 46 41.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 40 126.250000 4671.2500 37.0000
Subtotal (Total Children Is Unduplicated) 77 175.500000 4948.7500 28.1980
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.000000 397.0700 56.7243
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 14.500000 749.2500 51.6724
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.000000 266.1400 44.3567
Subtotal (Total Children Is Unduplicated) 14 30.500000 1637.4600 53.6872
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
INTR-T1013-INTERPRETER 15 29.750000 1487.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 10.000000 100.0000 10.0000
TRAV-TRAVS-Travel by mile 20 632.000000 274.0800 0.4337
Subtotal (Total Children Is Unduplicated) 28 678.750000 2211.5800 3.2583
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Total 884.750000 8797.7900 9.9438
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Number of Children (Unduplicated) With at Least One Service 84
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Center 01
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 87 692.250000 2886.5400 2886.5400
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
252 192.500000 5911.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 339 884.750000 8797.7900 2886.5400