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: 10-01-25 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 197 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
 PSTF  -97164       PT RE-EVAL EST PLAN CARE                     4          4            1.161111          $67.4700           $58.1100
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        4          4            1.161111          $67.4700           $58.1100


EI Services, Class # 03
 CONOF -CONOF       CONSULT, OT, FACE TO FACE                   46         49           23.673809        $1183.7000           $50.0000
 CONPF -CONPF       CONSULT, PT, FACE TO FACE                   11         11           14.909524         $745.4800           $50.0000
 CONSF -CONSF       CONSULT, SLP, FACE TO FACE                  76         80           26.240478        $1312.0300           $50.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF            36         37          314.285715       $16971.4300           $54.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                    2          2           20.714286        $1684.4900           $81.3200
 PHY   -97110       PT SESSION BY LICENSED PT                    3          3           27.000000        $2195.6400           $81.3200
 PHY   -97110HM     PT SESSION BY PT ASST                        1          1            2.857143         $186.0500           $65.1200
 SPL   -92507       SPL THERAPY SESSION BY LICENSED SLP          1          1            6.071429         $493.7300           $81.3200
 TRAV  -TRAVS       Travel by mile                               8          9           52.785714          $23.4900            $0.4500
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      138        193          488.538098       $24796.0300           $50.7600


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Total                                                                     197          489.699209       $24863.5000           $50.7700
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Number of Children (Unduplicated) With at Least One Authorization      138