CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7 10.500000 388.5000 37.0000
Subtotal (Total Children Is Unduplicated) 7 10.750000 397.7500 37.0000
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Total 10.750000 397.7500 37.0000
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Number of Children (Unduplicated) With at Least One Service 7
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Center 57
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
11 10.750000 397.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11 10.750000 397.7500 0.0000