CMS/EIP Fiscal Report Center: 53
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 68 141.000000 5245.2000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 86.500000 3217.8000 37.2000
Subtotal (Total Children Is Unduplicated) 72 229.250000 8463.0000 36.9160
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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 4 7.500000 562.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
Subtotal (Total Children Is Unduplicated) 10 21.500000 1398.0000 65.0233
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 4 2.750000 0.0000 0.0000
EPIC-99601-Early Steps Professional Development Fee 2 2.000000 30.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 3.000000 36.0000 12.0000
Subtotal (Total Children Is Unduplicated) 4 7.750000 66.0000 8.5161
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Total 258.500000 9927.0000 38.4023
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Number of Children (Unduplicated) With at Least One Service 75
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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 9 7.250000 269.7000 0.0000
S 2 1.000000 37.2000 0.0000
H 0 0.000000 0.0000 0.0000
T 6 9.500000 585.7500 585.7500
364 240.750000 9034.3500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 381 258.500000 9927.0000 585.7500