Summary Report for FSPSAs Initiated During the Report Period                                             Center: 52

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: 10-01-23 and 12-31-23                  Date of Report: 01-14-24                  Page: 1

    Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
   
With the filters selected there were 303 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                   2          2            1.255556           $0.0000            $0.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        2          2            1.255556           $0.0000            $0.0000


Screening, Eval, and Assessment, Class # 02
 SCREEN-T1023       SCREENING                                    2          2            2.000000         $100.0000           $50.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        2          2            2.000000         $100.0000           $50.0000


EI Services, Class # 03
 COIFF -COIFF       IFSP CONSULT, PROF, FACE TO FACE             3          3            5.766666         $288.3300           $50.0000
 CONIF -CONIF       CONSULT, ITDS FACE TO FACE                 103        121          347.023810       $17351.1900           $50.0000
 CONOF -CONOF       CONSULT, OT, FACE TO FACE                   60         75          187.190472        $9359.5000           $50.0000
 CONPF -CONPF       CONSULT, PT, FACE TO FACE                   38         43          101.866663        $5093.3200           $50.0000
 CONSF -CONSF       CONSULT, SLP, FACE TO FACE                  53         55          141.083334        $7054.1700           $50.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF             2          2           16.857143         $842.8600           $50.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      134        299          799.788088       $39989.3600           $50.0000


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Total                                                                     303          803.043644       $40089.3600           $49.9200
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Number of Children (Unduplicated) With at Least One Authorization      136