CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 14 13.750000 508.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.250000 83.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 36 69.500000 2571.5000 37.0000
Subtotal (Total Children Is Unduplicated) 37 91.500000 3163.5000 34.5738
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 3 2.500000 125.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 280.0000 280.0000
Subtotal (Total Children Is Unduplicated) 6 11.000000 889.5000 80.8636
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 2 2.000000 16.0000 8.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 70.000000 35.0000 0.5000
Subtotal (Total Children Is Unduplicated) 3 72.000000 51.0000 0.7083
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Total 174.500000 4104.0000 23.5186
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Number of Children (Unduplicated) With at Least One Service 37
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Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 8 6.000000 222.0000 0.0000
P 53 36.250000 1341.2500 1341.2500
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
67 40.250000 1615.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 130 85.250000 3280.7500 1341.2500
Center 53
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 12 12.250000 490.2500 490.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 74.000000 146.0000 146.0000
T 0 0.000000 0.0000 0.0000
1 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 22 88.250000 786.2500 636.2500
Center 55
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 1 1.000000 37.0000 37.0000
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 0 0.000000 0.0000 0.0000
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Total 1 1.000000 37.0000 37.0000