Summary Report for FSPSAs Initiated During the Report Period Center: 51
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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 280 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 4 4 4.677778 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 4 4 4.677778 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 19 19 18.177778 $927.9800 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 14 14 14.000000 $714.7000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.000000 $133.6500 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 41 48 47.177778 $2387.8800 $50.6100
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 2.033333 $101.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.133333 $56.6700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 1.200000 $60.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 1.666667 $83.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 46 49 400.604764 $20030.2400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 60 63 335.595238 $23974.8900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 10.142857 $724.6000 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 22.571429 $1612.5000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 19 19 171.167858 $12228.2200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 74 76 622.802383 $44492.9700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 23.571428 $1683.9400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 34.142857 $473.9000 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 5 5 23.047619 $852.7600 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 173 228 1649.679766 $106375.7000 $64.4800
-------------------------------------------------------------------------------------------------------------------------------------
Total 280 1701.535322 $108763.5800 $63.9200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 191