CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 Page: 1
List order: No List
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 1 1.250000 62.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 15.000000 750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 4.000000 30.0000 7.5000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 20.0000 20.0000
TRAV-TRAVS-Travel by mile 2 19.000000 5.3400 0.2811
Subtotal (Total Children Is Unduplicated) 9 40.250000 867.8400 21.5612
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Total 40.250000 867.8400 21.5612
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Number of Children (Unduplicated) With at Least One Service 9
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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 10 10.000000 500.0000 350.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
15 30.250000 367.8400 195.3400
Other 0 0.000000 0.0000 0.0000
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Total 25 40.250000 867.8400 545.3400