CMS/EIP Fiscal Report Center: 05
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 59 310.750000 11559.9000 37.2000
Subtotal (Total Children Is Unduplicated) 59 310.750000 11559.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
Subtotal (Total Children Is Unduplicated) 2 3.500000 232.3400 66.3829
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Total 314.250000 11792.2400 37.5250
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Number of Children (Unduplicated) With at Least One Service 59
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Center 05
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 283 237.750000 8844.3000 8537.4100
P 1 2.000000 119.8400 119.8400
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
42 41.000000 1581.9000 112.5000
Other 37 33.500000 1246.2000 1246.2000
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Total 363 314.250000 11792.2400 10015.9500