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

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: 10-01-25 and 12-31-25                  Date of Report: 01-07-26                  Page: 1

    Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
   
With the filters selected there were 10 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            2.188889          $99.9900           $45.6800
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        2          2            2.188889          $99.9900           $45.6800


EI Services, Class # 03
 COIFP -COIFP       IFSP CONSULT, PROF, BY PHONE                 1          1            3.033333          $75.8300           $25.0000
 CONIP -CONIP       CONSULT, ITDS PHONE                          1          1            1.400000          $35.0000           $25.0000
 CONOP -CONOP       CONSULT, OT, PHONE                           2          2            4.433333         $110.8300           $25.0000
 CONPF -CONPF       CONSULT, PT, FACE TO FACE                    1          1            4.142857         $207.1500           $50.0000
 EIIF  -EIIF_NM     EI INDIVIDUAL SESSION BY NONMED PRO          1          1            1.642857          $82.1500           $50.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                    2          2           21.285714        $1730.9500           $81.3200
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        6          8           35.938094        $2241.9100           $62.3800


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Total                                                                      10           38.126983        $2341.9000           $61.4200
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Number of Children (Unduplicated) With at Least One Authorization      8