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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 527 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 1.377778 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.377778 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 4 4 4.000000 $200.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 7 7 7.000000 $345.6000 $49.3700
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 4.666666 $233.3300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 11 14.950000 $747.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.750000 $18.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 157 201 490.566675 $24528.3800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 97 112 272.333336 $13616.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 51 121.566666 $6078.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 121 276.658336 $13832.9300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 36.666667 $1833.3400 $50.0000
INTR -T1013 INTERPRETER 6 6 78.904761 $3945.2400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 6.285714 $449.0500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 7.714286 $551.1100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 3 14.714286 $1051.1900 $71.4400
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Subtotal (Total Children Is Unduplicated) 209 518 1325.777393 $66885.8200 $50.4500
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Total 527 1334.155171 $67231.4200 $50.3900
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Number of Children (Unduplicated) With at Least One Authorization 215