CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 21 5.750000 212.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 34 113.750000 4208.7500 37.0000
Subtotal (Total Children Is Unduplicated) 47 120.000000 4421.5000 36.8458
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 10.500000 787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 47.000000 2608.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 34 77.500000 4827.7500 62.2935
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EI Services,Class #03
INTR-T1013-INTERPRETER 1 12.000000 600.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 12.000000 600.0000 50.0000
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Total 209.500000 9849.2500 47.0131
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Number of Children (Unduplicated) With at Least One Service 59
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Center 03
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 2 11.000000 550.0000 550.0000
T 0 0.000000 0.0000 0.0000
171 197.000000 9216.0000 0.0000
Other 1 1.500000 83.2500 0.0000
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Total 174 209.500000 9849.2500 550.0000