CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 32 64.750000 2395.7500 37.0000
Subtotal (Total Children Is Unduplicated) 32 64.750000 2395.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Total 64.750000 2395.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 32
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 73 44.750000 1655.7500 0.0000
P 40 20.000000 740.0000 740.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 113 64.750000 2395.7500 740.0000