CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 64 223.500000 8314.2000 37.2000
Subtotal (Total Children Is Unduplicated) 64 223.500000 8314.2000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.000000 637.0200 57.9109
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
Subtotal (Total Children Is Unduplicated) 7 15.000000 960.9400 64.0627
-----------------------------------------------------------------------------------------------------------------------
Total 238.500000 9275.1400 38.8895
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 64
-----------------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
189 238.500000 9275.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 189 238.500000 9275.1400 0.0000