CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 49 194.250000 7187.2500 37.0000
Subtotal (Total Children Is Unduplicated) 49 194.250000 7187.2500 37.0000
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Total 194.250000 7187.2500 37.0000
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Number of Children (Unduplicated) With at Least One Service 49
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Center 05
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 197 194.250000 7187.2500 2747.2500
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 0 0.000000 0.0000 0.0000
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Total 197 194.250000 7187.2500 2747.2500