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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 211 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 22 22 36.144446 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 22 36.144446 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 1.933334 $96.6700 $50.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.933334 $146.6700 $50.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.100000 $5.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 57 78 94.500778 $4725.0500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 19 19 11.774735 $294.3700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 17 17 21.616667 $1080.8400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 32.369047 $1618.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 15.733333 $786.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 12 11.933334 $596.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.000000 $75.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 14 15 69.428571 $3471.4400 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 10.680953 $763.0500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 2.428572 $173.5000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 8 38.428572 $2745.3400 $71.4400
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Subtotal (Total Children Is Unduplicated) 104 186 315.994562 $21435.3600 $67.8300
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Total 211 355.072342 $21582.0300 $60.7800
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Number of Children (Unduplicated) With at Least One Authorization 126