Summary Report for FSPSAs Initiated During the Report Period                                             Center: 57

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 765 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
 TCM   -T1017TL     TARGETED CASE MANAGEMENT                     5          5            3.766667         $140.1200           $37.2000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        5          5            3.766667         $140.1200           $37.2000


Screening, Eval, and Assessment, Class # 02
 OCTF  -97168       OT RE-EVAL EST PLAN CARE                     2          2            0.283334          $14.5700           $51.4200
 OCTH  -97167       OT EVAL HIGH COMPLEXITY                      2          2            1.016667          $52.2700           $51.4100
 SPCH  -92521       EVAL OF SPEECH FLUENCY                       2          2            0.122223           $6.2900           $51.4400
 SPCH  -92610       EVAL OF ORAL,PHARYNGEAL SWALLOWING           1          1            1.000000          $44.8600           $44.8600
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        5          7            2.422224         $117.9900           $48.7100


EI Services, Class # 03
 CONOF -CONOF       CONSULT, OT, FACE TO FACE                  307        316          235.611106       $11780.5400           $50.0000
 CONPF -CONPF       CONSULT, PT, FACE TO FACE                   40         42           44.984130        $2249.2200           $50.0000
 CONSF -CONSF       CONSULT, SLP, FACE TO FACE                 346        357          236.452377       $11822.6000           $50.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF            19         21          190.371429        $9518.5800           $50.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                    2          2            4.971429         $357.7400           $71.9600
 SPL   -92507       SPL THERAPY SESSION BY LICENSED SLP          3          3           10.928572         $786.4200           $71.9600
 TRAV  -TRAVS       Travel by mile                              11         12           54.798413          $24.3900            $0.4400
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      415        753          778.117456       $36539.4800           $46.9600


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Total                                                                     765          784.306347       $36797.5900           $46.9200
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Number of Children (Unduplicated) With at Least One Authorization      420