CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.500000 75.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 26.500000 981.0200 37.0196
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 1 8.000000 3.5600 0.4450
Subtotal (Total Children Is Unduplicated) 10 44.000000 1441.0200 32.7505
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Total 44.000000 1441.0200 32.7505
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Number of Children (Unduplicated) With at Least One Service 10
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Center 52
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 1 5.500000 275.0000 94.8200
16 38.500000 1166.0200 479.9600
Other 0 0.000000 0.0000 0.0000
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Total 17 44.000000 1441.0200 574.7800