CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 70 112.500000 4162.5000 37.0000
Subtotal (Total Children Is Unduplicated) 70 112.500000 4162.5000 37.0000
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Total 112.500000 4162.5000 37.0000
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Number of Children (Unduplicated) With at Least One Service 70
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Center 53
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
149 112.500000 4162.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 149 112.500000 4162.5000 0.0000