Summary Report for FSPSAs Initiated During the Report Period Center: 52
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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1470 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 14.911113 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 14 14 14.911113 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 2.000000 $100.0000 $50.0000
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 5 5.000000 $252.8200 $50.5600
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 6.166667 $308.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 6 36.433333 $1821.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 368 618 3606.535721 $180326.8200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 4 21.000000 $1050.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 5.466667 $136.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 207 313 2113.357150 $105667.8900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 111 189 1304.200007 $65210.0400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 202 287 1672.066669 $83603.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 12 16 79.980953 $1999.5300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 5 88.819047 $4440.9500 $50.0000
INTR -T1013 INTERPRETER 5 5 65.414286 $3270.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.025000 $217.6800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 24.857143 $1431.7700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 1 1 6.964286 $501.1500 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 12.933333 $930.6800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 10.866667 $781.9700 $71.9600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 428 1451 9058.086929 $451699.1900 $49.8700
-------------------------------------------------------------------------------------------------------------------------------------
Total 1470 9077.998042 $451952.0100 $49.7900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 440