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: 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 276 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
 AUDE  -V5010       ASSESSMENT FOR HEARING AID                   2          2            2.000000          $90.6400           $45.3200
 OCTF  -97168       OT RE-EVAL EST PLAN CARE                     2          4            0.700000          $40.6800           $58.1100
 PSTF  -97164       PT RE-EVAL EST PLAN CARE                     4          5            1.961111         $113.9600           $58.1100
 PSTH  -97163       PT EVAL HIGH COMPLEXITY                      1          1            1.000000          $58.1100           $58.1100
 SPCH  -92521       EVAL OF SPEECH FLUENCY                       1          1            0.088889           $5.1700           $58.1200
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        9         13            5.750000         $308.5500           $53.6600


EI Services, Class # 03
 CONOF -CONOF       CONSULT, OT, FACE TO FACE                   77         78           88.703169        $4435.1400           $50.0000
 CONPF -CONPF       CONSULT, PT, FACE TO FACE                   12         13           28.155557        $1407.7800           $50.0000
 CONSF -CONSF       CONSULT, SLP, FACE TO FACE                 122        122          119.965076        $5998.2400           $50.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF            31         31          305.000003       $16470.0000           $54.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                    2          4           21.428572        $1742.5700           $81.3200
 PHY   -97110       PT SESSION BY LICENSED PT                    4          4           24.714286        $2009.7700           $81.3200
 TRAV  -TRAVS       Travel by mile                               9         11           69.379365          $30.8700            $0.4500
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      187        263          657.346028       $32094.3600           $48.8200


-------------------------------------------------------------------------------------------------------------------------------------
Total                                                                     276          663.096028       $32402.9100           $48.8700
-------------------------------------------------------------------------------------------------------------------------------------

Number of Children (Unduplicated) With at Least One Authorization      188