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

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: 10-01-24 and 12-31-24                  Date of Report: 03-31-25                  Page: 1

    Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
   
With the filters selected there were 760 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                     2          2            0.844444          $31.4100           $37.2000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        2          2            0.844444          $31.4100           $37.2000


Screening, Eval, and Assessment, Class # 02
 OCTH  -97167       OT EVAL HIGH COMPLEXITY                      1          1            1.000000          $58.1100           $58.1100
 PSTF  -97164       PT RE-EVAL EST PLAN CARE                     7          7            3.022222         $175.6200           $58.1100
 PSTH  -97163       PT EVAL HIGH COMPLEXITY                      2          2            2.000000         $116.2200           $58.1100
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                       10         10            6.022222         $349.9500           $58.1100


EI Services, Class # 03
 COIFF -COIFF       IFSP CONSULT, PROF, FACE TO FACE             4          7            1.694445          $84.7300           $50.0000
 CONOF -CONOF       CONSULT, OT, FACE TO FACE                  244        255          222.934926       $11146.7900           $50.0000
 CONPF -CONPF       CONSULT, PT, FACE TO FACE                   37         39           56.928573        $2846.4400           $50.0000
 CONSF -CONSF       CONSULT, SLP, FACE TO FACE                 373        387          230.403180       $11520.1900           $50.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF            42         44          279.909521       $15115.1200           $54.0000
 PHY   -97110       PT SESSION BY LICENSED PT                    6          6           52.000000        $4228.6400           $81.3200
 TRAV  -TRAVS       Travel by mile                               9         10           57.814287          $25.7300            $0.4500
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      469        748          901.684932       $44967.6300           $49.8700


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Total                                                                     760          908.551598       $45348.9900           $49.9100
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Number of Children (Unduplicated) With at Least One Authorization      472