CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/10/2023 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 96 154.000000 5728.8000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 48 149.000000 5542.8000 37.2000
Subtotal (Total Children Is Unduplicated) 103 304.500000 11271.6000 37.0167
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 5.000000 375.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 13 16.500000 915.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 20 41.000000 2753.2500 67.1524
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
EPIC-99601-Early Steps Professional Development Fee 1 1.000000 15.0000 15.0000
Subtotal (Total Children Is Unduplicated) 1 1.500000 15.0000 10.0000
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Total 347.000000 14039.8500 40.4607
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Number of Children (Unduplicated) With at Least One Service 107
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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 7 9.500000 588.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5 5.000000 277.5000 222.0000
473 332.500000 13173.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 485 347.000000 14039.8500 222.0000