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
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 542 1287.500000 47895.0000 37.2000
Subtotal (Total Children Is Unduplicated) 542 1287.500000 47895.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 27.500000 1526.2500 55.5000
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 21 32.500000 1801.2500 55.4231
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Total 1320.000000 49696.2500 37.6487
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Number of Children (Unduplicated) With at Least One Service 544
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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
1996 1320.000000 49696.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1996 1320.000000 49696.2500 0.0000