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
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 124 125.250000 4634.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 25 31.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 41 161.250000 5966.2500 37.0000
Subtotal (Total Children Is Unduplicated) 133 317.750000 10600.5000 33.3611
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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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 21.428933 1607.1700 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
Subtotal (Total Children Is Unduplicated) 19 44.428933 3101.1700 69.8007
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Total 362.178933 13701.6700 37.8312
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Number of Children (Unduplicated) With at Least One Service 133
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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 0 0.000000 0.0000 0.0000
P 5 10.000000 672.0000 672.0000
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 5 10.000000 672.0000 672.0000
430 342.178933 12357.6700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 440 362.178933 13701.6700 1344.0000