Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 817 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 26 26 12.933335 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 26 26 12.933335 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.550000 $26.6800 $48.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.166667 $8.5100 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.394444 $20.1300 $51.0400
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Subtotal (Total Children Is Unduplicated) 4 4 1.111111 $55.3200 $49.7900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 21 82 17.867462 $893.3900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.100000 $5.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.433333 $21.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.533333 $26.6700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 10.428571 $260.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 13 14 113.714286 $5685.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 594 684 4667.381703 $46673.8500 $10.0000
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.285714 $245.1400 $57.2000
PHY -97110HM PT SESSION BY PT ASST 1 1 10.142857 $579.7700 $57.1600
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Subtotal (Total Children Is Unduplicated) 615 787 4824.887259 $54391.9000 $11.2700
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Total 817 4838.931705 $54447.2200 $11.2500
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Number of Children (Unduplicated) With at Least One Authorization 641