CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2014 ending 03/31/2014 Date of Report:06/03/2014 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 12 6.750000 249.7500 37.0000
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3.000000 0.0000 0.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 22 41.250000 1526.2500 37.0000
Subtotal (Total Children Is Unduplicated) 24 51.500000 1794.5000 34.8447
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Screening, Eval, and Assessment,Class #02
EVAL-EVAL-DEVELOPMENTAL EVALUATION 1 0.500000 25.0000 50.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 0.500000 37.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 40.5000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 22.1400 22.1400
Subtotal (Total Children Is Unduplicated) 3 6.000000 330.6400 55.1067
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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 59.500000 2141.1400 35.9855
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Number of Children (Unduplicated) With at Least One Service 24
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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 1 1.500000 55.5000 0.0000
P 35 31.750000 1174.7500 1174.7500
D 3 3.500000 205.5000 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
33 19.250000 575.8900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 72 56.000000 2011.6400 1174.7500
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
Center 57
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
2 3.000000 111.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2 3.000000 111.0000 0.0000