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: 01-01-17 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 833 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 3 3 1.733333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.733333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 7.743575 $375.5600 $48.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.277778 $14.1800 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.888889 $45.3800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 6 1.333334 $68.0700 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 1.233333 $62.9600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.571429 $29.1700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.477778 $24.3900 $51.0500
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Subtotal (Total Children Is Unduplicated) 23 25 12.526116 $619.7200 $49.4700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 53 10.666665 $533.3300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 17 17 7.361111 $368.0600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 10.194443 $509.7200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 2.300000 $115.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 2.866666 $143.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 23 23 175.142856 $8757.1400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 632 674 5040.783317 $50407.8700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 36.285713 $2592.2600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 40.428571 $2888.2200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 7.714286 $551.1100 $71.4400
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Subtotal (Total Children Is Unduplicated) 655 805 5333.743628 $66866.0200 $12.5400
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Total 833 5348.003077 $67485.7300 $12.6200
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Number of Children (Unduplicated) With at Least One Authorization 664