CMS/EIP Fiscal Report Center: 53
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:OTHER
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 7 9.000000 450.0000 50.0000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 3 290.000000 145.0000 0.5000
Subtotal (Total Children Is Unduplicated) 10 299.000000 595.0000 1.9900
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Total 299.000000 595.0000 1.9900
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Number of Children (Unduplicated) With at Least One Service 10
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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 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
12 299.000000 595.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 12 299.000000 595.0000 0.0000