CMS/EIP Fiscal Report Center: 05
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 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 5 2.250000 83.7000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 4.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 7.500000 279.0000 37.2000
Subtotal (Total Children Is Unduplicated) 8 14.500000 362.7000 25.0138
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
Subtotal (Total Children Is Unduplicated) 1 3.500000 241.3100 68.9457
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 4.000000 48.0000 12.0000
TRAV-TRAVS-Travel by mile 5 103.000000 45.8300 0.4450
Subtotal (Total Children Is Unduplicated) 5 107.000000 93.8300 0.8769
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Total 125.000000 697.8400 5.5827
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Number of Children (Unduplicated) With at Least One Service 8
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Center 05
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 11 110.500000 335.1400 335.1400
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 0 0.000000 0.0000 0.0000
21 14.500000 362.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 32 125.000000 697.8400 335.1400