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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 170 278.250000 10350.9000 37.2000
Subtotal (Total Children Is Unduplicated) 170 278.250000 10350.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 404.9000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.000000 539.2800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 11.000000 890.7800 80.9800
SCREEN-T1023-SCREENING 1 1.000000 53.9800 53.9800
Subtotal (Total Children Is Unduplicated) 15 28.000000 2008.7800 71.7421
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 54.0000 54.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 54.0000 54.0000
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Total 307.250000 12413.6800 40.4025
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Number of Children (Unduplicated) With at Least One Service 171
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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
501 307.250000 12413.6800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 501 307.250000 12413.6800 0.0000