CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 86 112.000000 4144.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 57 31.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 57 175.750000 6465.7500 36.7895
Subtotal (Total Children Is Unduplicated) 112 319.500000 10609.7500 33.2074
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 24.000000 1800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 16.500000 915.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 27 66.000000 4628.2500 70.1250
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 11 10.500000 0.0000 0.0000
INTR-T1013-INTERPRETER 10 18.500000 925.0000 50.0000
TRAV-TRAVS-Travel by mile 6 135.000000 60.0900 0.4451
Subtotal (Total Children Is Unduplicated) 22 164.000000 985.0900 6.0066
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Total 549.500000 16223.0900 29.5234
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Number of Children (Unduplicated) With at Least One Service 115
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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 370 545.000000 16028.8400 16028.8400
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
3 3.000000 111.0000 0.0000
Other 1 1.500000 83.2500 0.0000
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Total 374 549.500000 16223.0900 16028.8400