CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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 3 4.000000 200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 36.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 0.750000 53.9700 71.9600
TRAV-TRAVS-Travel by mile 1 50.000000 22.2400 0.4448
Subtotal (Total Children Is Unduplicated) 5 58.750000 384.1700 6.5391
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Total 58.750000 384.1700 6.5391
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Number of Children (Unduplicated) With at Least One Service 5
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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 0 0.000000 0.0000 0.0000
13 58.750000 384.1700 37.6000
Other 0 0.000000 0.0000 0.0000
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Total 13 58.750000 384.1700 37.6000