CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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
Screening, Eval, and Assessment,Class #02
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 1 1.000000 51.4100 51.4100
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EI Services,Class #03
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 25.0000 25.0000
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Total 2.000000 76.4100 38.2050
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Number of Children (Unduplicated) With at Least One Service 2
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Center 55
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
2 2.000000 76.4100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2 2.000000 76.4100 0.0000