Summary Report for FSPSAs Initiated During the Report Period Center: 57
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: 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 1175 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 1.600000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.600000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 2.000000 $154.2600 $77.1300
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 5 2.277778 $116.2800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 19 19 8.244443 $420.8700 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 2.144444 $109.4700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.333333 $17.0200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 3.950001 $201.6500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 22 23 8.249999 $421.1600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 11 11 5.855555 $298.9200 $51.0500
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Subtotal (Total Children Is Unduplicated) 54 79 33.055553 $1739.6300 $52.6300
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 79 79 46.984124 $2349.2000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 21.980953 $1099.0500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 254 260 124.049203 $6202.4400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 13 13 96.571430 $4828.5800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 383 667 2845.661950 $28456.5900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 59.071429 $4220.0500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 9 9 98.714285 $7052.1400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 16.071428 $918.6500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 51.071429 $3648.5400 $71.4400
TRAV -TRAVS Travel by mile 14 32 13610.746034 $6056.7800 $0.4500
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Subtotal (Total Children Is Unduplicated) 389 1093 16970.922265 $64832.0100 $3.8200
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Total 1175 17005.577818 $66571.6500 $3.9100
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Number of Children (Unduplicated) With at Least One Authorization 403