CMS/EIP Fiscal Report Center: 57
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 4 29.500000 1097.4000 37.2000
Subtotal (Total Children Is Unduplicated) 4 29.500000 1097.4000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 242.9400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 389.4800 59.9200
Subtotal (Total Children Is Unduplicated) 4 13.000000 915.8500 70.4500
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Total 42.500000 2013.2500 47.3706
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Number of Children (Unduplicated) With at Least One Service 4
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Center 57
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 23 42.500000 2013.2500 2013.2500
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 23 42.500000 2013.2500 2013.2500