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: 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 83 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                     1          1            0.788889          $36.0400           $45.6800
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        1          1            0.788889          $36.0400           $45.6800


EI Services, Class # 03
 CONOF -CONOF       CONSULT, OT, FACE TO FACE                   20         20           22.988890        $1149.4600           $50.0000
 CONPF -CONPF       CONSULT, PT, FACE TO FACE                    3          3            6.358730         $317.9400           $50.0000
 CONSF -CONSF       CONSULT, SLP, FACE TO FACE                  31         31           46.677779        $2333.8900           $50.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF            24         24          270.857140       $14626.2900           $54.0000
 TRAV  -TRAVS       Travel by mile                               3          4           31.000000          $13.8000            $0.4500
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                       68         82          377.882539       $18441.3700           $48.8000


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Total                                                                      83          378.671428       $18477.4100           $48.8000
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Number of Children (Unduplicated) With at Least One Authorization      69