Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 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 597 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 14 16 15.679364 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 16 15.679364 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $16.7000 $16.7000
EXIT -EXIT EXIT ASSESSMENT 76 76 119.347164 $5967.3400 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 0.013699 $0.7600 $55.5100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 78 79 121.360863 $6035.8500 $49.7300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 80 105 83.387704 $4169.4100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 16 19 12.136114 $303.4100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 156 184 478.304761 $23915.2400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.300000 $57.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 67 129.190476 $6459.5300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 31 55.490476 $2774.5200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 72 76 141.871432 $7093.5900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 3.571429 $89.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7 7 33.809524 $1690.4800 $50.0000
INTR -T1013 INTERPRETER 4 5 7.428571 $371.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 7.428571 $530.7000 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.428571 $316.3800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 17.714286 $1265.5000 $71.4400
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Subtotal (Total Children Is Unduplicated) 225 502 977.061915 $49036.9700 $50.1900
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Total 597 1114.102142 $55072.8200 $49.4300
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Number of Children (Unduplicated) With at Least One Authorization 283