CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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 148 193.500000 7159.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 3.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 40 148.000000 5476.0000 37.0000
Subtotal (Total Children Is Unduplicated) 154 344.500000 12635.5000 36.6778
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.006934 1050.5200 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 11.533333 865.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 19 41.540267 2820.5200 67.8985
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
TRAV-TRAVS-Travel by mile 1 28.000000 12.4600 0.4450
Subtotal (Total Children Is Unduplicated) 1 29.000000 22.4600 0.7745
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Total 415.040267 15478.4800 37.2939
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Number of Children (Unduplicated) With at Least One Service 154
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Center 55
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 12 48.533333 1320.4600 1320.4600
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
520 366.506934 14158.0200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 532 415.040267 15478.4800 1320.4600