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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 715 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 3 1.055555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 3 1.055555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 2.644445 $128.2600 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.126027 $6.3000 $49.9900
NURS -T1001 NURSING ASSESSMENT 1 1 1.142857 $57.1500 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.383333 $19.5700 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 8.873810 $453.0100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.500000 $25.5300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 4 11.527778 $588.4900 $51.0500
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Subtotal (Total Children Is Unduplicated) 21 24 25.198250 $1278.3000 $50.7300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 53 10.005554 $500.2700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 6.108567 $305.4300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 2.577778 $128.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 19.714286 $985.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 23 29 142.195238 $7109.7700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 518 586 3552.169071 $35521.6600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 43.857144 $3133.1400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 4 20.714286 $1479.8200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 2 10.571429 $755.2200 $71.4400
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Subtotal (Total Children Is Unduplicated) 539 688 3807.913353 $49919.9100 $13.1100
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Total 715 3834.167158 $51198.2100 $13.3500
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Number of Children (Unduplicated) With at Least One Authorization 545