CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 6 3.500000 129.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 2.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 2.000000 74.0000 37.0000
Subtotal (Total Children Is Unduplicated) 6 7.750000 203.5000 26.2581
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Total 7.750000 203.5000 26.2581
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Number of Children (Unduplicated) With at Least One Service 6
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Center 02
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
0 0.000000 0.0000 0.0000
Other 20 7.750000 203.5000 0.0000
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Total 20 7.750000 203.5000 0.0000