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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 678 1779.750000 65850.7500 37.0000
Subtotal (Total Children Is Unduplicated) 678 1779.750000 65850.7500 37.0000
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Total 1779.750000 65850.7500 37.0000
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Number of Children (Unduplicated) With at Least One Service 678
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Center 05
Flag Claims Units Chgs Paid
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R 11 9.000000 333.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2545 1735.250000 64204.2500 27088.6300
P 0 0.000000 0.0000 0.0000
D 1 0.500000 18.5000 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
26 12.000000 444.0000 0.0000
Other 30 23.000000 851.0000 0.0000
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Total 2613 1779.750000 65850.7500 27088.6300