CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 124 125.250000 4634.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 25 31.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 136 564.500000 20886.5000 37.0000
Subtotal (Total Children Is Unduplicated) 140 721.000000 25520.7500 35.3963
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 72 142.000000 10650.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 92.500000 6937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 56.000000 4200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 30.000000 1665.0000 55.5000
Subtotal (Total Children Is Unduplicated) 92 335.500000 24463.5000 72.9165
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EI Services,Class #03
PHY-97110HM-PT SESSION BY PT ASST 2 13.000000 743.0800 57.1600
Subtotal (Total Children Is Unduplicated) 2 13.000000 743.0800 57.1600
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Total 1069.500000 50727.3300 47.4309
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Number of Children (Unduplicated) With at Least One Service 140
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Center 55
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 1 0.500000 18.5000 0.0000
P 411 530.127600 24414.0700 24414.0700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.666667 200.0000 0.0000
T 9 18.000000 1272.0000 1272.0000
542 518.205733 24822.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 965 1069.500000 50727.3300 25686.0700