Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 10-01-15 and 12-31-15 Date of Report: 02-12-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 554 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.243836 $11.8200 $48.4900
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.072222 $3.6900 $51.0300
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 0.516666 $26.3700 $51.0400
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.072222 $3.6900 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.033333 $1.7000 $51.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6 6 0.938279 $47.2700 $50.3800
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 13 1.477776 $73.8800 $49.9900
CONIF -CONIF CONSULT, FACE TO FACE 1 1 0.677778 $33.8900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 25 25 148.917024 $7445.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 433 499 2827.347441 $28273.4800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 16.285714 $1163.4500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 1.857143 $132.6700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 24.428572 $1745.1700 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 1 8.285714 $4.1400 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 442 548 3029.277162 $38872.5500 $12.8300
-------------------------------------------------------------------------------------------------------------------------------------
Total 554 3030.215441 $38919.8200 $12.8400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 443