Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 10-01-19 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 2113 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 28 28 16.566666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 28 28 16.566666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 1.355555 $65.7400 $48.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 6 6 1.661112 $84.8000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.138889 $7.0900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 98 98 27.459528 $1401.8300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 1.733334 $88.4900 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.455556 $23.2600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.422222 $21.5500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 73 75 30.714283 $1567.9500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 48 49 38.302380 $1955.3300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.233333 $11.9100 $51.0400
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.450000 $22.0200 $48.9400
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Subtotal (Total Children Is Unduplicated) 184 242 102.926192 $5249.9900 $51.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 84 23.189682 $1159.4900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 1.411112 $70.5600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.644445 $132.2300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.111111 $55.5600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 94 100 647.571435 $16189.2800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 605 633 4705.732534 $235286.7600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 606 654 4701.747612 $47017.5000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 73 74 450.044440 $32151.1400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 73 75 478.680953 $27380.5300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 54 57 426.857146 $30494.7000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 63 66 401.185715 $22931.7700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 18 84.999999 $6072.4100 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 84.285714 $4821.1400 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 65 67 361.071432 $5011.6600 $13.8800
TRAV -TRAVS Travel by mile 1 1 2.142857 $0.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 766 1843 12373.676187 $433775.6700 $35.0600
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Total 2113 12493.169045 $439025.6500 $35.1400
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Number of Children (Unduplicated) With at Least One Authorization 793