CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2022 ending 09/30/2022 Date of Report:10/18/2022 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 67 105.500000 3887.4500 36.8479
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 9.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 22 59.000000 2183.0000 37.0000
Subtotal (Total Children Is Unduplicated) 72 173.500000 6070.4500 34.9882
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
Subtotal (Total Children Is Unduplicated) 6 10.000000 584.2500 58.4250
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 9 11.250000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13 20.000000 200.0000 10.0000
TRAV-TRAVS-Travel by mile 4 115.000000 51.1700 0.4450
Subtotal (Total Children Is Unduplicated) 13 146.250000 251.1700 1.7174
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Total 329.750000 6905.8700 20.9427
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Number of Children (Unduplicated) With at Least One Service 73
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Center 53
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 20 10.000000 370.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4 49.000000 40.9100 40.9100
301 270.000000 6467.2100 0.0000
Other 1 0.750000 27.7500 0.0000
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Total 326 329.750000 6905.8700 40.9100