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
Eligibility Filter: Program Patients
With the filters selected there were 2947 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 0.969841 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 13.514286 $500.0300 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 14.484127 $500.0300 $34.5200
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.827778 $42.2600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 41 42 26.957142 $1376.1500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 9 9 1.716666 $87.6300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.494444 $25.2400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 37 40 37.882540 $1933.9000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.122222 $6.2400 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 62 62 33.912699 $1731.2400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.705556 $34.5300 $48.9400
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Subtotal (Total Children Is Unduplicated) 120 161 102.619047 $5237.2000 $51.0400
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 145 155 77.100788 $3855.0200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.172222 $4.3100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 9.215078 $460.7500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 361 395 222.029357 $11101.4400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 1.722222 $43.0600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 78 115 549.557939 $13738.9400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 777 858 5536.044414 $276802.3200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 769 863 5461.953937 $54619.5600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 85 111 361.714285 $25840.8600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 10 28.428571 $1626.1100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 65 81 378.867458 $27066.2900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 6 6 25.642857 $1465.7400 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 107 137 531.447616 $37966.6200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 10 11 28.071429 $389.6300 $13.8800
TRAV -TRAVS Travel by mile 15 15 12729.999999 $5664.8500 $0.4500
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Subtotal (Total Children Is Unduplicated) 870 2781 25941.968172 $460645.4900 $17.7600
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Total 2947 26059.071346 $466382.7100 $17.9000
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Number of Children (Unduplicated) With at Least One Authorization 873