CMS/EIP Fiscal Report Center: 52
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 17 11.000000 407.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 27 14.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 112.500000 4153.2500 36.9178
Subtotal (Total Children Is Unduplicated) 52 138.250000 4560.2500 32.9855
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 2 8.000000 561.0000 70.1250
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 8.000000 80.0000 10.0000
TRAV-TRAVS-Travel by mile 44 1025.000000 455.9900 0.4449
Subtotal (Total Children Is Unduplicated) 44 1033.500000 535.9900 0.5186
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Total 1179.750000 5657.2400 4.7953
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Number of Children (Unduplicated) With at Least One Service 58
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Center 52
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 27 23.000000 703.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 84 1041.000000 1096.9900 1036.9900
109 115.750000 3857.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 220 1179.750000 5657.2400 1036.9900