CMS/EIP Fiscal Report Center: 53
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 77 152.250000 5633.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 89 170.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 31 139.000000 5143.0000 37.0000
Subtotal (Total Children Is Unduplicated) 99 461.250000 10776.2500 23.3631
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 8 18.000000 1291.5000 71.7500
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.750000 87.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.750000 37.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.500000 25.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 74 76.250000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 81 148.000000 1480.0000 10.0000
TRAV-TRAVS-Travel by mile 23 442.000000 196.6500 0.4449
Subtotal (Total Children Is Unduplicated) 81 669.250000 1826.6500 2.7294
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Total 1148.500000 13894.4000 12.0979
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Number of Children (Unduplicated) With at Least One Service 103
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Center 53
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 1 0.500000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 36 366.500000 623.5100 623.5100
799 781.500000 13270.8900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 836 1148.500000 13894.4000 623.5100