CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 58 156.500000 5821.8000 37.2000
Subtotal (Total Children Is Unduplicated) 58 156.500000 5821.8000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
Subtotal (Total Children Is Unduplicated) 3 5.000000 277.5000 55.5000
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Total 161.500000 6099.3000 37.7666
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Number of Children (Unduplicated) With at Least One Service 58
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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
125 161.500000 6099.3000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 125 161.500000 6099.3000 0.0000