CMS/EIP Fiscal Report Center: 09
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 102 173.250000 6410.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 47 35.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 54 167.500000 6197.5000 37.0000
Subtotal (Total Children Is Unduplicated) 126 376.250000 12607.7500 33.5090
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 25.500000 1912.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 20.500000 1137.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 34 78.500000 5487.7500 69.9076
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 6 4.250000 0.0000 0.0000
INTR-T1013-INTERPRETER 9 28.250000 1412.5000 50.0000
TRAV-TRAVS-Travel by mile 8 375.000000 164.2200 0.4379
Subtotal (Total Children Is Unduplicated) 20 407.500000 1576.7200 3.8693
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Total 862.250000 19672.2200 22.8150
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Number of Children (Unduplicated) With at Least One Service 131
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Center 09
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 418 862.250000 19672.2200 19672.2200
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 418 862.250000 19672.2200 19672.2200