CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2025 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 8 21.750000 809.1000 37.2000
Subtotal (Total Children Is Unduplicated) 8 21.750000 809.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
Subtotal (Total Children Is Unduplicated) 3 8.000000 563.6000 70.4500
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Total 29.750000 1372.7000 46.1412
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Number of Children (Unduplicated) With at Least One Service 8
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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
22 29.750000 1372.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 22 29.750000 1372.7000 0.0000