Summary Report for FSPSAs Initiated During the Report Period                                             Center: 51

This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.

FSPSAs starting between: 10-01-22 and 12-31-22                  Date of Report: 01-23-23                  Page: 1

    Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
   
With the filters selected there were 14 FSPSA's found 


Services  Cpt Code                                       Number of   Number of       Total Units    Total Cost of          Avg Fee
                                                         Children    Records         Authorized     Auth Services       Per Unit Auth



Service Coordination, Class # 01
 SCONLY-SCONLY      *SERVICE COORDINATION ONLY                   1          1            4.285714           $0.0000            $0.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        1          1            4.285714           $0.0000            $0.0000


Screening, Eval, and Assessment, Class # 02
 OCTH  -97165       OT EVAL LOW COMPLEXITY                       1          1            1.000000          $51.4100           $51.4100
 OCTH  -97167       OT EVAL HIGH COMPLEXITY                      1          1            1.000000          $51.4100           $51.4100
 PSTH  -97163       PT EVAL HIGH COMPLEXITY                      1          1            1.000000          $51.4100           $51.4100
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        3          3            3.000000         $154.2300           $51.4100


EI Services, Class # 03
 EIIF  -96154       HEALTH AND BEHAVIOR INTERVENTION             3          3           16.719047         $835.9500           $50.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                    2          2           12.571429         $904.6400           $71.9600
 SPL   -92507       SPL THERAPY SESSION BY LICENSED SLP          5          5           35.142858        $2528.8800           $71.9600
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        8         10           64.433334        $4269.4600           $66.2600


-------------------------------------------------------------------------------------------------------------------------------------
Total                                                                      14           71.719048        $4423.6900           $61.6800
-------------------------------------------------------------------------------------------------------------------------------------

Number of Children (Unduplicated) With at Least One Authorization      11