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: 01-01-17 and 03-31-17 Date of Report: 05-05-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1783 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 1.077778 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.077778 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.061111 $99.9600 $48.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.138889 $7.0900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 38 40 7.961108 $406.4000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 27 29 23.134921 $1181.0400 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.294445 $15.0300 $51.0600
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.177777 $9.0700 $51.0300
PSTH -97001 EVAL BY LICENSED PT, INITIAL 34 34 32.385715 $1653.2900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 25 27 22.676191 $1157.6300 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.044444 $2.2700 $51.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 47 49 29.583332 $1510.2200 $51.0500
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Subtotal (Total Children Is Unduplicated) 145 187 118.457933 $6042.0000 $51.0100
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.194444 $13.9200 $71.5900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 76 18.244443 $912.2200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 0.744445 $37.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.122222 $6.1100 $49.9900
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 7.633334 $381.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 1.433334 $71.6700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 85 105 560.999993 $14025.0200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 529 577 3702.433334 $185121.7800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 503 560 3599.745236 $35997.4700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 85 98 490.205556 $35020.3000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 73 83 479.999996 $34291.2600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.500000 $257.2200 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 80 337.523014 $24112.6600 $71.4400
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Subtotal (Total Children Is Unduplicated) 672 1594 9203.779351 $330248.5100 $35.8800
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Total 1783 9323.315062 $336290.5200 $36.0700
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Number of Children (Unduplicated) With at Least One Authorization 683