CMS/EIP Fiscal Report Center: 03
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 60 28.500000 1054.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 35 36.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 49 141.000000 5217.0000 37.0000
Subtotal (Total Children Is Unduplicated) 96 205.750000 6271.5000 30.4812
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 43.500000 3262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.500000 862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 36.000000 1998.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
SCREEN-T1023-SCREENING 5 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 40 130.500000 8793.5000 67.3831
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Total 336.250000 15065.0000 44.8030
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Number of Children (Unduplicated) With at Least One Service 99
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Center 03
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
383 336.250000 15065.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 383 336.250000 15065.0000 0.0000