Summary Report for FSPSAs Ending During the Report Period Center: 52
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: 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 578 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 1.100000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.100000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 2 2 2.000000 $100.0000 $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) 5 5 5.000000 $245.6000 $49.1200
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.866666 $143.3300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 20 23.950000 $1197.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 172 225 425.185715 $21259.2900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 105 123 259.583328 $12979.1400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 54 59 138.757140 $6937.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 116 248.766663 $12438.3200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 9 35.204762 $1760.2400 $50.0000
INTR -T1013 INTERPRETER 11 14 112.295238 $5614.7500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 1.000000 $71.4400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 5.866667 $419.1200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 2.428571 $173.5000 $71.4400
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Subtotal (Total Children Is Unduplicated) 213 571 1255.904750 $62994.4600 $50.1600
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Total 578 1262.004750 $63240.0600 $50.1100
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Number of Children (Unduplicated) With at Least One Authorization 218