CMS/EIP Fiscal Report Center: 07
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 2 6.000000 222.0000 37.0000
Subtotal (Total Children Is Unduplicated) 2 6.000000 222.0000 37.0000
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Total 6.000000 222.0000 37.0000
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Number of Children (Unduplicated) With at Least One Service 2
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Center 07
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 4 3.000000 111.0000 0.0000
P 6 3.000000 111.0000 111.0000
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
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Total 10 6.000000 222.0000 111.0000