CMS/EIP Fiscal Report Center: 05
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 73 267.500000 9951.0000 37.2000
Subtotal (Total Children Is Unduplicated) 73 267.500000 9951.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 1 1.500000 112.5000 75.0000
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Total 269.000000 10063.5000 37.4108
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Number of Children (Unduplicated) With at Least One Service 73
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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 251 217.500000 8091.0000 7495.8100
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
4 3.000000 168.3000 112.5000
Other 59 48.500000 1804.2000 1804.2000
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Total 314 269.000000 10063.5000 9412.5100