Summary Report for FSPSAs Ending During the Report Period Center: 57
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1368 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 4 4 3.083333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 3.083333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 7 5.550793 $283.3700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 5.373015 $274.2900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 8 1.988889 $101.5300 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 14 14 7.184127 $366.7500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 8.911903 $454.9500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 6 6 1.361112 $69.4900 $51.0500
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Subtotal (Total Children Is Unduplicated) 50 67 30.547617 $1559.4600 $51.0500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.833333 $41.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 78 82 54.133333 $2706.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 11.869842 $593.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 269 286 196.739680 $9836.9700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 3.999999 $100.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 15 66.428570 $3321.4400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 405 827 3112.055571 $31120.5600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 44.642858 $3189.2700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 6 42.571428 $3041.3200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 7 7 70.642857 $4037.9500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 17.714284 $1265.5200 $71.4400
TRAV -TRAVS Travel by mile 27 37 19084.587306 $8492.6400 $0.4500
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Subtotal (Total Children Is Unduplicated) 413 1297 22706.219061 $67747.5000 $2.9800
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Total 1368 22739.850011 $69306.9600 $3.0500
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Number of Children (Unduplicated) With at Least One Authorization 428