CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 47 40.250000 1497.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 31 185.750000 6909.9000 37.2000
Subtotal (Total Children Is Unduplicated) 62 226.000000 8407.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 242.9400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 9.500000 569.2400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 16.500000 988.6800 59.9200
Subtotal (Total Children Is Unduplicated) 23 31.500000 1971.7200 62.5943
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Total 257.500000 10378.9200 40.3065
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Number of Children (Unduplicated) With at Least One Service 63
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Center 04
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
192 257.500000 10378.9200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 192 257.500000 10378.9200 0.0000