BASIC (03-86)

DI 39503.812 Exhibit C-Medical Cost Data

State/Region             

 

MEDICAL COST DATA

 

 FY 19FY 19FY 19FY 19

A.

TITLE II

    
 

Cases Processed

                                     

 

No. of cases with CE's CE Rate

                                     

 

CE RATE

                                     

 

CE Case Cost

                                     

 

CE Total Cost

                                     

 

No. of MER's

                                     

 

MER Rate

                                     

 

MER Case Cost

                                     

 

MER Total Cost

                                     

B.

TITLE XVI

    
 

Cases Processed

                                     

 

No. of cases with CE's

                                     

 

CE Rate

                                     

 

CE Case Cost

                                     

 

CE Total Cost

                                     

 

No. of MER's

                                     

 

MER Rate

                                     

 

MER Case Cost

                                     

 

MER Total Cost

                                     

C.

TITLE II/XVI CONC.

    
 

Cases Processed

                                     

 

No. of cases with CE's

                                     

 

CE Rate

                                     

 

CE Case Cost

                                     

 

CE Total Cost

                                     

 

No. of MER's

                                     

 

MER Rate

                                     

 

MER Case Cost

                                     

 

MER Total Cost

                                     

D.

Total Medical Costs
(Total A + B + C)

                                     

 

Cases Processed

                                     

 

No. of cases with CE's

                                     

 

CE Rate

                                     

 

CE Case Cost

                                     

 

CE Total Cost