Summary Report for FSPSAs Initiated During the Report Period                                             Center: 10

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: 10-01-20 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 237 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  -92553       PURE TONE AUDIOMETRY AIR & BONE             90         90           97.142857        $2281.8900           $23.4900
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                       90         90           97.142857        $2281.8900           $23.4900


EI Services, Class # 03
 CONIF -CONIF       CONSULT, ITDS FACE TO FACE                  57         57           83.382540        $4169.1300           $50.0000
 CONOF -CONOF       CONSULT, OT, FACE TO FACE                   10         10            9.488889         $474.4500           $50.0000
 CONPF -CONPF       CONSULT, PT, FACE TO FACE                   22         22           21.627777        $1081.3900           $50.0000
 CONSF -CONSF       CONSULT, SLP, FACE TO FACE                  29         29           34.633334        $1731.6700           $50.0000
 CONSP -CONSP       CONSULT, SLP, PHONE                          1          1            0.533333          $13.3300           $25.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF             4          4           55.428571        $2771.4300           $50.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                    4          4           30.544443        $2182.1000           $71.4400
 OCCT  -97530HM     OT SESSION BY OT ASST                        1          1            8.285714         $473.9400           $57.2000
 PHY   -97110       PT SESSION BY LICENSED PT                    5          5           53.714285        $3837.3600           $71.4400
 SPL   -92507       SPL THERAPY SESSION BY LICENSED SLP         13         14          126.038095        $9004.1700           $71.4400
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                       82        147          423.676981       $25738.9500           $60.7500


-------------------------------------------------------------------------------------------------------------------------------------
Total                                                                     237          520.819838       $28020.8400           $53.8000
-------------------------------------------------------------------------------------------------------------------------------------

Number of Children (Unduplicated) With at Least One Authorization      160