CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 598 1842.750000 68502.6000 37.1741
Subtotal (Total Children Is Unduplicated) 598 1842.750000 68502.6000 37.1741
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Total 1842.750000 68502.6000 37.1741
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Number of Children (Unduplicated) With at Least One Service 598
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Center 05
Flag Claims Units Chgs Paid
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R 6 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 2937 1814.750000 67462.1000 31536.1400
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
2 0.750000 27.9000 0.0000
Other 35 24.250000 901.0000 0.0000
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Total 2980 1842.750000 68502.6000 31536.1400