CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 57 165.250000 6147.3000 37.2000
Subtotal (Total Children Is Unduplicated) 57 165.250000 6147.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.500000 449.4000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
Subtotal (Total Children Is Unduplicated) 5 8.500000 509.3200 59.9200
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Total 173.750000 6656.6200 38.3115
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Number of Children (Unduplicated) With at Least One Service 59
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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
130 173.750000 6656.6200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 130 173.750000 6656.6200 0.0000