CMS/EIP Fiscal Report Center: 51
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 34 66.500000 2460.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 20 22.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 18 66.500000 2460.5000 37.0000
Subtotal (Total Children Is Unduplicated) 38 155.750000 4921.0000 31.5955
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 8.500000 637.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 13.500000 749.2500 55.5000
Subtotal (Total Children Is Unduplicated) 15 28.000000 1836.7500 65.5982
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 7 7.000000 70.0000 10.0000
Subtotal (Total Children Is Unduplicated) 7 7.000000 70.0000 10.0000
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Total 190.750000 6827.7500 35.7942
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Number of Children (Unduplicated) With at Least One Service 43
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Center 51
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 16 16.000000 725.5000 725.5000
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
230 174.750000 6102.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 246 190.750000 6827.7500 725.5000