CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 14 19.250000 712.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 15 30.750000 1137.7500 37.0000
Subtotal (Total Children Is Unduplicated) 18 50.000000 1850.0000 37.0000
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Total 50.000000 1850.0000 37.0000
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Number of Children (Unduplicated) With at Least One Service 18
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Center 04
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
66 50.000000 1850.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 66 50.000000 1850.0000 0.0000