CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 392 772.000000 28718.4000 37.2000
Subtotal (Total Children Is Unduplicated) 392 772.000000 28718.4000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 479.3600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 179.7600 59.9200
SCREEN-T1023-SCREENING 3 3.000000 161.9400 53.9800
Subtotal (Total Children Is Unduplicated) 9 14.000000 821.0600 58.6471
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Total 786.000000 29539.4600 37.5820
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Number of Children (Unduplicated) With at Least One Service 393
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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
1082 786.000000 29539.4600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1082 786.000000 29539.4600 0.0000