CMS/EIP Fiscal Report Center: 09
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 77 83.750000 3098.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 60 32.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 56 155.250000 5744.2500 37.0000
Subtotal (Total Children Is Unduplicated) 107 271.000000 8843.0000 32.6310
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.500000 787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 18.000000 1350.0000 75.0000
Subtotal (Total Children Is Unduplicated) 27 48.500000 3569.2500 73.5928
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 3.000000 0.0000 0.0000
INTR-T1013-INTERPRETER 7 16.000000 800.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 9 404.000000 179.8000 0.4450
Subtotal (Total Children Is Unduplicated) 18 424.000000 1051.2400 2.4793
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Total 743.500000 13463.4900 18.1083
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Number of Children (Unduplicated) With at Least One Service 110
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Center 09
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 316 743.500000 13463.4900 13463.4900
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 316 743.500000 13463.4900 13463.4900