CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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
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
EPIC-99601-Early Steps Professional Development Fee 1 2.000000 30.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 12.0000 12.0000
OCCT-97530HM-OT SESSION BY OT ASST 1 1.307125 85.1200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 325.2800 81.3200
Subtotal (Total Children Is Unduplicated) 5 9.307125 477.4000 51.2940
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Total 10.307125 528.8100 51.3053
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Number of Children (Unduplicated) With at Least One Service 6
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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
11 10.307125 528.8100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11 10.307125 528.8100 0.0000