Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 793 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 35 35 17.661112 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 35 17.661112 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 15 10.477778 $508.1700 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $27.8300 $27.8300
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.250000 $12.7600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 28 30 16.116666 $822.7500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.077778 $3.9700 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 29 32 14.112177 $720.4300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 23 27 16.556242 $845.2000 $51.0500
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Subtotal (Total Children Is Unduplicated) 82 107 58.590641 $2941.1300 $50.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 14 11.714156 $58571.0000 $5000.0200
CONIF -CONIF CONSULT, ITDS FACE TO FACE 14 14 16.977778 $848.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 67 78.866668 $3943.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 30 40.100001 $2005.0100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 0.744444 $37.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 97 114 113.611115 $5680.5800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.766667 $88.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 215 296 1230.533322 $61526.6800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 11.000000 $550.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 41 214.009519 $15288.8700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.571429 $89.8800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 30 41 188.561901 $13470.8700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 25 30 152.719048 $10910.2500 $71.4400
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Subtotal (Total Children Is Unduplicated) 317 651 2062.176048 $173010.9300 $83.9000
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Total 793 2138.427801 $175952.0500 $82.2800
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Number of Children (Unduplicated) With at Least One Authorization 349