CMS/EIP Fiscal Report Center: 04
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 1 3.000000 111.6000 37.2000
Subtotal (Total Children Is Unduplicated) 1 3.000000 111.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
Subtotal (Total Children Is Unduplicated) 1 2.000000 140.9000 70.4500
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Total 5.000000 252.5000 50.5000
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Number of Children (Unduplicated) With at Least One Service 1
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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 1 3.000000 111.6000 111.6000
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
2 2.000000 140.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3 5.000000 252.5000 111.6000