CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 28 11.250000 409.2000 36.3733
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 31 127.500000 4733.7000 37.1271
Subtotal (Total Children Is Unduplicated) 48 141.000000 5142.9000 36.4745
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 100.0000 50.0000
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 8 3.750000 0.0000 0.0000
TRAV-TRAVS-Travel by mile 27 378.000000 168.1500 0.4448
Subtotal (Total Children Is Unduplicated) 29 381.750000 168.1500 0.4405
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Total 524.750000 5411.0500 10.3117
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Number of Children (Unduplicated) With at Least One Service 59
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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 31 380.000000 268.1500 268.1500
153 144.750000 5142.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 184 524.750000 5411.0500 268.1500