CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 18 7.750000 288.3000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 38 148.500000 5542.8000 37.3253
Subtotal (Total Children Is Unduplicated) 48 158.000000 5831.1000 36.9057
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 32.000000 1776.0000 55.5000
Subtotal (Total Children Is Unduplicated) 16 40.000000 2376.0000 59.4000
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 1.000000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 36.0000 12.0000
TRAV-TRAVS-Travel by mile 18 215.000000 95.6700 0.4450
Subtotal (Total Children Is Unduplicated) 20 219.000000 131.6700 0.6012
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Total 417.000000 8338.7700 19.9971
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Number of Children (Unduplicated) With at Least One Service 54
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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 5 4.750000 176.7000 0.0000
H 0 0.000000 0.0000 0.0000
T 27 226.000000 731.6700 696.8700
175 186.250000 7430.4000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 207 417.000000 8338.7700 696.8700