Summary Report for FSPSAs Initiated During the Report Period Center: 07
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 604 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 14 9.338887 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 9.338887 $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 69 69 108.673973 $5433.6900 $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) 71 72 110.687672 $5502.2000 $49.7100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 73 104 89.824610 $4491.2600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 14 17 9.036114 $225.9100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 158 175 441.291666 $22064.5800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.833333 $141.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 3 4.866667 $121.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 83 153.952382 $7697.6300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 41 82.052380 $4102.6200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 77 167.766670 $8388.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 4 10.399999 $260.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 44.009523 $2200.4800 $50.0000
INTR -T1013 INTERPRETER 2 3 4.285714 $214.2900 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 7.142857 $510.2900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 28.571429 $2041.1400 $71.4400
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Subtotal (Total Children Is Unduplicated) 216 518 1046.033344 $52459.8600 $50.1500
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Total 604 1166.059903 $57962.0600 $49.7100
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Number of Children (Unduplicated) With at Least One Authorization 276