Summary Report for FSPSAs Initiated During the Report Period Center: 52
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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 927 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 2 2 3.266666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 3.266666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 2.000000 $250.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 15 15 12.676560 $647.1500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 5.733333 $292.6800 $51.0500
SCREEN-T1023 SCREENING 28 28 25.849250 $1292.4600 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 5.082192 $259.4500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 7.244445 $369.8300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 65 70 61.585780 $3263.6700 $52.9900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 10 7.408297 $370.4200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.066667 $26.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 147 173 363.030506 $18151.4700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 107 126 286.505479 $14325.2700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 60 130.688888 $6534.4400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 120 124 271.516664 $13575.8200 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 6.995238 $349.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 143 157 854.996505 $42749.8200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 45 52 189.961902 $13570.8900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 13 54.366667 $3109.7700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 35 37 146.586903 $10472.1500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.571429 $204.1400 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 91 97 595.798816 $42563.8200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 4.702381 $65.2700 $13.8800
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Subtotal (Total Children Is Unduplicated) 287 855 2917.196342 $166069.6900 $56.9300
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Total 927 2982.048788 $169333.3600 $56.7800
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Number of Children (Unduplicated) With at Least One Authorization 302