CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2019 ending 06/30/2019 Date of Report:07/21/2019 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 66 98.000000 3579.7500 36.5281
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 78 90.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 22 105.250000 3838.7500 36.4727
Subtotal (Total Children Is Unduplicated) 84 293.750000 7418.5000 25.2545
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Screening, Eval, and Assessment,Class #02
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 3 5.000000 277.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
Subtotal (Total Children Is Unduplicated) 5 13.000000 877.5000 67.5000
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 72 69.750000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 78 149.000000 1490.0000 10.0000
TRAV-TRAVS-Travel by mile 26 232.000000 103.1500 0.4446
Subtotal (Total Children Is Unduplicated) 78 450.750000 1593.1500 3.5344
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Total 757.500000 9889.1500 13.0550
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Number of Children (Unduplicated) With at Least One Service 85
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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 47 164.000000 395.9000 395.9000
T 0 0.000000 0.0000 0.0000
659 593.500000 9493.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 706 757.500000 9889.1500 395.9000