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: 01-01-16 and 03-31-16 Date of Report: 05-12-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 711 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 2 2 2.577778 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 2.577778 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.488889 $23.7100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 0.661112 $33.7500 $51.0600
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 1.627778 $83.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.472222 $24.1100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.050000 $53.6000 $51.0500
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Subtotal (Total Children Is Unduplicated) 16 17 4.300001 $218.2700 $50.7600
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 33 77 21.932544 $1096.6500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 7 7 5.994444 $299.7200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 9.142857 $228.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 22 22 137.285712 $6864.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 527 574 3491.505507 $34915.0700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 29.142857 $2081.9700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 17.571429 $1255.3000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 20.142856 $1439.0100 $71.4400
TRAV -TRAVS Travel by mile 1 1 3.857143 $1.7200 $0.4400
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Subtotal (Total Children Is Unduplicated) 556 692 3736.575349 $48182.3000 $12.8900
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Total 711 3743.453128 $48400.5700 $12.9300
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Number of Children (Unduplicated) With at Least One Authorization 562