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
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 10 3.500000 129.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 2.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 32 148.250000 5411.2500 36.5008
Subtotal (Total Children Is Unduplicated) 40 154.500000 5540.7500 35.8625
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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 728.000000 5794.7700 7.9598
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Number of Children (Unduplicated) With at Least One Service 48
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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 40 571.000000 254.0200 254.0200
130 157.000000 5540.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 170 728.000000 5794.7700 254.0200