CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 40 15.750000 582.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 39 38.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 53 185.750000 6872.7500 37.0000
Subtotal (Total Children Is Unduplicated) 86 239.750000 7455.5000 31.0970
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 10.000000 527.2500 52.7250
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 13 28.500000 1914.7500 67.1842
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
INTR-T1013-INTERPRETER 23 40.750000 2037.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 20.000000 200.0000 10.0000
TRAV-TRAVS-Travel by mile 12 392.000000 167.2000 0.4265
Subtotal (Total Children Is Unduplicated) 34 457.750000 2654.7000 5.7995
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Total 726.000000 12024.9500 16.5633
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Number of Children (Unduplicated) With at Least One Service 98
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Center 01
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 62 428.500000 1219.7000 1219.7000
D 0 0.000000 0.0000 0.0000
S 25 14.500000 481.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.500000 75.0000 75.0000
387 281.500000 10249.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 475 726.000000 12024.9500 1294.7000