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: 10-01-19 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 1036 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 1 1 0.555556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.555556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 3 3 3.000000 $150.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 9.000000 $459.4500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 6.433333 $328.4200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 42 43 42.800000 $2140.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 6.285714 $320.8900 $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 17 17 17.200000 $878.0600 $51.0500
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Subtotal (Total Children Is Unduplicated) 76 84 89.719047 $4532.0700 $50.5100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.722222 $3611.0000 $4999.8500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 6.100000 $436.8200 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 16 19.850001 $992.5100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 189 235 572.449994 $28622.4700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 100 122 340.433334 $17021.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 57 61 148.876185 $7443.7900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 127 310.200001 $15510.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 3.200000 $80.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 175 183 995.269047 $49763.4600 $50.0000
INTR -T1013 INTERPRETER 9 9 78.561905 $3928.0900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 49 234.261904 $16735.6800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 20 22 171.180951 $9791.5500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 43 44 234.226191 $16733.1200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.142857 $179.6500 $57.1600
SENS -V5264 EARMOLD 1 1 3.733333 $67.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 72 368.585712 $26331.7700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 25.933332 $359.9500 $13.8800
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Subtotal (Total Children Is Unduplicated) 313 951 3516.726969 $197608.7200 $56.1900
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Total 1036 3607.001572 $202140.7900 $56.0400
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Number of Children (Unduplicated) With at Least One Authorization 343