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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 973 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 0.747619 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.747619 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.227778 $11.6300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 4 0.683334 $34.8900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.177778 $9.0800 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 2 0.511111 $26.0900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 1.427778 $72.8900 $51.0500
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Subtotal (Total Children Is Unduplicated) 8 14 3.027779 $154.5700 $51.0500
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 87 89 43.277776 $2163.8800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 6.037301 $301.8700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 217 235 135.220634 $6761.0300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.305556 $7.6400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 12 53.557936 $1338.9500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 32 35 205.000001 $10250.0100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 492 546 3571.939660 $35719.4100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 28.285714 $2020.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.428571 $196.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 2 2 9.000000 $642.9600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.500000 $200.0600 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 22.785714 $1627.8200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 5.857143 $81.3000 $13.8800
TRAV -TRAVS Travel by mile 10 10 8980.714284 $3996.4200 $0.4500
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Subtotal (Total Children Is Unduplicated) 503 957 13068.910290 $65308.1800 $5.0000
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Total 973 13072.685688 $65462.7500 $5.0100
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Number of Children (Unduplicated) With at Least One Authorization 505