CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 12 6.250000 231.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 3.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 21 105.000000 3885.0000 37.0000
Subtotal (Total Children Is Unduplicated) 27 114.500000 4116.2500 35.9498
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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 20 311.000000 138.3300 0.4448
Subtotal (Total Children Is Unduplicated) 20 312.000000 138.3300 0.4434
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Total 426.500000 4254.5800 9.9756
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Number of Children (Unduplicated) With at Least One Service 34
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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 22 311.000000 138.3300 138.3300
103 115.500000 4116.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 125 426.500000 4254.5800 138.3300