CMS/EIP Fiscal Report Center: 57
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 35 16.250000 601.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 21.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 46 272.750000 10091.7500 37.0000
Subtotal (Total Children Is Unduplicated) 75 310.250000 10693.0000 34.4658
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 7.500000 562.5000 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 10 12.500000 693.7500 55.5000
Subtotal (Total Children Is Unduplicated) 11 26.000000 1681.2500 64.6635
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 11.000000 110.0000 10.0000
TRAV-TRAVS-Travel by mile 1 147.000000 65.4100 0.4450
Subtotal (Total Children Is Unduplicated) 4 158.000000 175.4100 1.1102
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Total 494.250000 12549.6600 25.3913
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Number of Children (Unduplicated) With at Least One Service 76
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Center 57
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 7 158.000000 175.4100 175.4100
246 336.250000 12374.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 253 494.250000 12549.6600 175.4100