CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 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 18 9.750000 342.2500 35.1026
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 0.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 17 76.250000 2812.0000 36.8787
Subtotal (Total Children Is Unduplicated) 27 86.500000 3154.2500 36.4653
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 1 4.000000 261.0000 65.2500
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 1.000000 0.0000 0.0000
TRAV-TRAVS-Travel by mile 8 263.000000 117.0000 0.4449
Subtotal (Total Children Is Unduplicated) 8 264.000000 117.0000 0.4432
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Total 354.500000 3532.2500 9.9640
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Number of Children (Unduplicated) With at Least One Service 27
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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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 14 267.000000 378.0000 338.0000
87 87.500000 3154.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 101 354.500000 3532.2500 338.0000