CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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 5 2.500000 92.5000 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 25 41.000000 1517.0000 37.0000
Subtotal (Total Children Is Unduplicated) 25 45.500000 1609.5000 35.3736
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 27.2200 27.2200
Subtotal (Total Children Is Unduplicated) 2 4.000000 227.2200 56.8050
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 2 2.000000 16.0000 8.0000
Subtotal (Total Children Is Unduplicated) 2 2.000000 16.0000 8.0000
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Total 51.500000 1852.7200 35.9751
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Number of Children (Unduplicated) With at Least One Service 25
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Center 04
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 38 26.000000 962.0000 0.0000
P 10 11.750000 434.7500 434.7500
D 1 1.500000 55.5000 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
20 11.750000 381.9700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 69 51.000000 1834.2200 434.7500
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 0.500000 18.5000 18.5000
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 0.500000 18.5000 18.5000