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
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 16 5.750000 213.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 95.000000 3501.5500 36.8584
Subtotal (Total Children Is Unduplicated) 33 102.000000 3715.4500 36.4260
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 1 6.000000 411.0000 68.5000
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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 566.500000 4330.2100 7.6438
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Number of Children (Unduplicated) With at Least One Service 40
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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 2 4.000000 261.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 27 460.000000 353.7600 333.7600
110 102.500000 3715.4500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 139 566.500000 4330.2100 333.7600