CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 ending 09/30/2018 Date of Report:11/06/2018 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 46 47.750000 1766.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 60 69.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 25 100.500000 3709.2500 36.9080
Subtotal (Total Children Is Unduplicated) 65 218.000000 5476.0000 25.1193
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Screening, Eval, and Assessment,Class #02
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 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 15.500000 860.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 12.500000 937.5000 75.0000
Subtotal (Total Children Is Unduplicated) 12 31.500000 2021.2500 64.1667
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 50 53.250000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 57 113.000000 1130.0000 10.0000
TRAV-TRAVS-Travel by mile 18 203.000000 90.3900 0.4453
Subtotal (Total Children Is Unduplicated) 58 370.250000 1270.3900 3.4312
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Total 619.750000 8767.6400 14.1471
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Number of Children (Unduplicated) With at Least One Service 72
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Center 53
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 0 0.000000 0.0000 0.0000
H 20 61.500000 409.4900 409.4900
T 17 78.000000 230.8300 230.8300
492 480.250000 8127.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 529 619.750000 8767.6400 640.3200