Summary Report for FSPSAs Ending During the Report Period                                             Center: 09

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: 10-01-20 and 12-31-20                  Date of Report: 01-23-21                  Page: 1

    Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
   
With the filters selected there were 209 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
 CASE  -CASE        NON-TCM CASE MANAGEMENT                      1          1            1.966667          $72.7700           $37.0000
 SCONLY-SCONLY      *SERVICE COORDINATION ONLY                  21         22           46.260316           $0.0000            $0.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                       22         23           48.226983          $72.7700            $1.5100


EI Services, Class # 03
 COIFF -COIFF       IFSP CONSULT, PROF, FACE TO FACE            42         66          100.818873        $5040.9400           $50.0000
 COIFP -COIFP       IFSP CONSULT, PROF, BY PHONE                17         22           21.266340         $531.6600           $25.0000
 CONIF -CONIF       CONSULT, ITDS FACE TO FACE                  21         22           51.288889        $2564.4500           $50.0000
 CONIP -CONIP       CONSULT, ITDS PHONE                          1          1            0.155556           $3.8900           $25.0100
 CONOF -CONOF       CONSULT, OT, FACE TO FACE                   16         16           17.661904         $883.1000           $50.0000
 CONPF -CONPF       CONSULT, PT, FACE TO FACE                   18         18           25.288889        $1264.4500           $50.0000
 CONSF -CONSF       CONSULT, SLP, FACE TO FACE                  23         23           32.580953        $1629.0500           $50.0000
 CONSP -CONSP       CONSULT, SLP, PHONE                          2          2            1.155556          $28.8900           $25.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF             9          9           62.842856        $3142.1500           $50.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                    3          4           12.633333         $902.5200           $71.4400
 SPL   -92507       SPL THERAPY SESSION BY LICENSED SLP          3          3            7.857143         $561.3200           $71.4400
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                       96        186          333.550292       $16552.4100           $49.6200


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Total                                                                     209          381.777275       $16625.1700           $43.5500
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Number of Children (Unduplicated) With at Least One Authorization      118