CMS/EIP Fiscal Report Center: 05
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 41 20.750000 767.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 42 48.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 46 167.000000 6179.0000 37.0000
Subtotal (Total Children Is Unduplicated) 61 236.250000 6946.7500 29.4042
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 19.000000 1425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 17.500000 1312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 21.000000 1165.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 7.500000 562.5000 75.0000
Subtotal (Total Children Is Unduplicated) 31 66.500000 4548.7500 68.4023
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 15 25.000000 250.0000 10.0000
TRAV-TRAVS-Travel by mile 31 944.000000 420.0300 0.4449
Subtotal (Total Children Is Unduplicated) 32 969.000000 670.0300 0.6915
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Total 1271.750000 12165.5300 9.5660
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Number of Children (Unduplicated) With at Least One Service 61
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Center 05
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 104 907.500000 4834.9500 4834.9500
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
331 364.250000 7330.5800 383.8300
Other 0 0.000000 0.0000 0.0000
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Total 435 1271.750000 12165.5300 5218.7800