Summary Report for FSPSAs Ending During the Report Period                                             Center: 03

This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending between: 07-01-24 and 09-30-24                  Date of Report: 04-06-25                  Page: 1

    Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
   
With the filters selected there were 220 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                  44         45           34.028570           $0.0000            $0.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                       44         45           34.028570           $0.0000            $0.0000


Screening, Eval, and Assessment, Class # 02
 ASTE  -ASTE        ASSISTIVE TECHNOLOGY EVAL                    1          2            2.000000          $97.0000           $48.5000
 OCTH  -97167       OT EVAL HIGH COMPLEXITY                      4          4            3.144445         $182.7300           $58.1100
 PSTH  -97163       PT EVAL HIGH COMPLEXITY                      2          2            2.000000         $116.2200           $58.1100
 SPCH  -92523       EVAL OF SPCH SOUND PROD; EVAL LANG           2          2            1.427778          $82.9700           $58.1100
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        7         10            8.572223         $478.9200           $55.8700


EI Services, Class # 03
 CONIF -CONIF       CONSULT, ITDS FACE TO FACE                  10         10           10.288890         $514.4500           $50.0000
 CONOF -CONOF       CONSULT, OT, FACE TO FACE                   28         29           33.433337        $1671.6900           $50.0000
 CONPF -CONPF       CONSULT, PT, FACE TO FACE                   27         28           27.250002        $1362.5100           $50.0000
 CONSF -CONSF       CONSULT, SLP, FACE TO FACE                  40         49           50.150005        $2507.5300           $50.0000
 EIIF  -EIIF_NM     EI INDIVIDUAL SESSION BY NONMED PRO          1          1            3.266667         $163.3400           $50.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF            29         30          103.099999        $5567.4100           $54.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                    7          7           13.428571        $1092.0100           $81.3200
 PHY   -97110       PT SESSION BY LICENSED PT                    6          6           12.571428        $1022.3100           $81.3200
 SPL   -92507       SPL THERAPY SESSION BY LICENSED SLP          5          5           14.233333        $1157.4500           $81.3200
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      121        165          267.722232       $15058.7000           $56.2500


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Total                                                                     220          310.323025       $15537.6100           $50.0700
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Number of Children (Unduplicated) With at Least One Authorization      165