CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 132 104.750000 3892.4500 37.1594
Subtotal (Total Children Is Unduplicated) 132 104.750000 3892.4500 37.1594
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Total 104.750000 3892.4500 37.1594
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Number of Children (Unduplicated) With at Least One Service 132
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Center 07
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
0 0.000000 0.0000 0.0000
Other 225 104.750000 3892.4500 0.0000
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Total 225 104.750000 3892.4500 0.0000