CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 16 5.750000 213.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 43 170.750000 6318.7000 37.0056
Subtotal (Total Children Is Unduplicated) 43 177.750000 6532.6000 36.7516
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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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 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 34 70.000000 5080.0000 72.5714
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 28.000000 1950.0000 69.6429
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 30 60.000000 3330.0000 55.5000
Subtotal (Total Children Is Unduplicated) 35 174.000000 11521.0000 66.2126
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 0.500000 0.0000 0.0000
TRAV-TRAVS-Travel by mile 22 458.000000 203.7600 0.4449
Subtotal (Total Children Is Unduplicated) 23 458.500000 203.7600 0.4444
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Total 810.250000 18257.3600 22.5330
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Number of Children (Unduplicated) With at Least One Service 43
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Center 52
Flag Claims Units Chgs Paid
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R 2 4.000000 261.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 58.750000 3123.9500 0.0000
P 45 70.750000 3801.7000 3450.3900
D 12 24.000000 1527.0000 0.0000
S 21 15.750000 585.9000 0.0000
H 7 14.000000 1050.0000 0.0000
T 36 478.000000 1354.3100 1254.3100
132 145.000000 6553.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 295 810.250000 18257.3600 4704.7000