Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 10-01-15 and 12-31-15 Date of Report: 02-12-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1913 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.219052 $8.1100 $37.0100
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Subtotal (Total Children Is Unduplicated) 1 1 0.219052 $8.1100 $37.0100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 2.054947 $99.6600 $48.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 6 1.144444 $58.4200 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 17 10.000001 $510.5100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 7 1.494444 $76.2900 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 6.922221 $353.3700 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.511111 $26.0900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 14 20.630158 $1053.1700 $51.0500
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Subtotal (Total Children Is Unduplicated) 42 59 42.757326 $2177.5200 $50.9300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 33 27.246030 $1362.2900 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 5 10 2.672221 $133.6100 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 9.571429 $239.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 9.857142 $246.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 233 273 2287.097312 $114355.0500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1173 1474 12319.783861 $123198.0300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 20 127.999999 $9144.3300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 15.714286 $898.8600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 14 16 100.642857 $7189.9200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.714286 $269.4700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 20 151.428570 $10818.0700 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 1 8.285714 $4.1400 $0.5000
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Subtotal (Total Children Is Unduplicated) 1215 1853 15065.013707 $267859.4700 $17.7800
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Total 1913 15107.990085 $270045.1000 $17.8700
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Number of Children (Unduplicated) With at Least One Authorization 1222