Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 491 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 32 33 27.950000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 32 33 27.950000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 55 55 53.223766 $2661.2000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 0.071233 $3.9500 $55.4700
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.071233 $5.3400 $74.9700
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 58 59 55.366232 $2772.5900 $50.0800
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 1.487672 $74.3800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 92 107 78.027107 $3901.3900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 4.716667 $117.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 121 154 338.990475 $16949.5100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 1.799999 $45.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 27 57.119048 $2855.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.966667 $49.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 37.033334 $1851.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.466666 $36.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 52 55 110.209525 $5510.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.233333 $30.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 12 107.285714 $5364.2900 $50.0000
INTR -T1013 INTERPRETER 3 3 41.442857 $2072.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.285714 $234.7300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 4.857142 $347.0000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 14.000000 $1000.1600 $71.4400
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Subtotal (Total Children Is Unduplicated) 197 399 805.921920 $40491.2800 $50.2400
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Total 491 889.238152 $43263.8700 $48.6500
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Number of Children (Unduplicated) With at Least One Authorization 273