CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 97 157.250000 5818.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 35 22.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 56 168.500000 6234.5000 37.0000
Subtotal (Total Children Is Unduplicated) 118 348.250000 12052.7500 34.6095
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 14.500000 1087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 42.000000 3150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 14.500000 804.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 23.500000 1762.5000 75.0000
Subtotal (Total Children Is Unduplicated) 41 111.500000 8079.7500 72.4641
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 7 5.500000 0.0000 0.0000
INTR-T1013-INTERPRETER 7 11.000000 550.0000 50.0000
TRAV-TRAVS-Travel by mile 8 475.000000 205.5100 0.4327
Subtotal (Total Children Is Unduplicated) 20 491.500000 755.5100 1.5372
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Total 951.250000 20888.0100 21.9585
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Number of Children (Unduplicated) With at Least One Service 121
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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 381 846.000000 18917.3800 18917.3800
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
19 100.750000 1633.1300 0.0000
Other 3 4.500000 337.5000 0.0000
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Total 403 951.250000 20888.0100 18917.3800