CMS/EIP Fiscal Report Center: 03
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 36 49.250000 1832.1000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 45 160.500000 5970.6000 37.2000
Subtotal (Total Children Is Unduplicated) 64 211.500000 7802.7000 36.8922
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 47.500000 2636.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 32 68.500000 4186.2500 61.1131
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 5.000000 50.0000 10.0000
TRAV-TRAVS-Travel by mile 3 73.000000 32.4700 0.4448
Subtotal (Total Children Is Unduplicated) 3 79.000000 132.4700 1.6768
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Total 359.000000 12121.4200 33.7644
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Number of Children (Unduplicated) With at Least One Service 73
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Center 03
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 0 0.000000 0.0000 0.0000
235 359.000000 12121.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 235 359.000000 12121.4200 0.0000