CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 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 26 45.250000 2067.0200 45.6800
Subtotal (Total Children Is Unduplicated) 26 45.250000 2067.0200 45.6800
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.500000 749.0000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.000000 971.7600 80.9800
Subtotal (Total Children Is Unduplicated) 11 24.500000 1720.7600 70.2351
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Total 69.750000 3787.7800 54.3051
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Number of Children (Unduplicated) With at Least One Service 30
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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
54 69.750000 3787.7800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 54 69.750000 3787.7800 0.0000