CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
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 10 3.500000 129.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 2.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 66 288.750000 10609.7500 36.7437
Subtotal (Total Children Is Unduplicated) 66 295.000000 10739.2500 36.4042
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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 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 99.500000 6802.5000 68.3668
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 18.000000 1350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 16.000000 1050.0000 65.6250
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 95.500000 5189.2500 54.3377
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
Subtotal (Total Children Is Unduplicated) 53 273.000000 17457.7500 63.9478
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 5 2.500000 0.0000 0.0000
TRAV-TRAVS-Travel by mile 29 571.000000 254.0200 0.4449
Subtotal (Total Children Is Unduplicated) 29 573.500000 254.0200 0.4429
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Total 1141.500000 28451.0200 24.9242
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Number of Children (Unduplicated) With at Least One Service 66
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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 27 41.250000 1830.2500 0.0000
P 119 201.750000 10165.0900 10045.3000
D 11 22.000000 1260.0000 0.0000
S 2 4.000000 261.0000 0.0000
H 18 36.000000 2505.0000 0.0000
T 67 625.000000 3625.4300 3223.4300
157 211.000000 8785.7500 53.6100
Other 1 0.500000 18.5000 0.0000
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Total 402 1141.500000 28451.0200 13322.3400