CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 1 1.000000 58.1100 58.1100
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EI Services,Class #03
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 1 0.500000 25.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.000000 108.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 1 1.000000 15.0000 15.0000
Subtotal (Total Children Is Unduplicated) 4 3.500000 148.0000 42.2857
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Total 4.500000 206.1100 45.8022
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Number of Children (Unduplicated) With at Least One Service 4
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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
5 4.500000 206.1100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5 4.500000 206.1100 0.0000