CMS/EIP Fiscal Report Center: 53
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 54 79.500000 2941.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 73 94.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 113.000000 4144.0000 36.6726
Subtotal (Total Children Is Unduplicated) 79 286.750000 7085.5000 24.7097
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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 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.500000 305.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
Subtotal (Total Children Is Unduplicated) 4 11.000000 678.7500 61.7045
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.250000 62.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.250000 12.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.750000 37.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 57 73.500000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 65 143.000000 1430.0000 10.0000
TRAV-TRAVS-Travel by mile 18 472.000000 210.1000 0.4451
Subtotal (Total Children Is Unduplicated) 65 691.750000 1802.6000 2.6059
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Total 989.500000 9566.8500 9.6684
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Number of Children (Unduplicated) With at Least One Service 86
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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 16 111.250000 138.3500 138.3500
T 35 273.500000 512.7200 512.7200
619 604.750000 8915.7800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 670 989.500000 9566.8500 651.0700