CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 5.000000 250.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 8.000000 543.0400 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 40.000000 20.0000 0.5000
Subtotal (Total Children Is Unduplicated) 3 53.000000 813.0400 15.3404
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Total 53.000000 813.0400 15.3404
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Number of Children (Unduplicated) With at Least One Service 3
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Center 03
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
14 53.000000 813.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14 53.000000 813.0400 0.0000