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

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: 04-01-25 and 06-30-25                  Date of Report: 07-19-25                  Page: 1

    Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
   
With the filters selected there were 39 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



Screening, Eval, and Assessment, Class # 02
 OCTH  -97165       OT EVAL LOW COMPLEXITY                       1          1            1.000000          $58.1100           $58.1100
 PSTH  -97161       PT EVAL LOW COMPLEXITY                       2          2            2.000000         $116.2200           $58.1100
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        3          3            3.000000         $174.3300           $58.1100


EI Services, Class # 03
 CONIF -CONIF       CONSULT, ITDS FACE TO FACE                   1          1            0.500000          $25.0000           $50.0000
 CONOF -CONOF       CONSULT, OT, FACE TO FACE                    1          2            2.000000         $100.0000           $50.0000
 CONOP -CONOP       CONSULT, OT, PHONE                           1          1            0.500000          $12.5000           $25.0000
 CONSF -CONSF       CONSULT, SLP, FACE TO FACE                   2          3            2.133333         $106.6700           $50.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF            12         12           87.071428        $4701.8600           $54.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                    6          6           14.285715        $1161.7100           $81.3200
 PHY   -97110       PT SESSION BY LICENSED PT                    4          4            8.576190         $697.4200           $81.3200
 SPL   -92507       SPL THERAPY SESSION BY LICENSED SLP          7          7           40.714286        $3310.8900           $81.3200
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                       23         36          155.780952       $10116.0400           $64.9400


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Total                                                                      39          158.780952       $10290.3700           $64.8100
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Number of Children (Unduplicated) With at Least One Authorization      25