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
Eligibility Filter: Program Patients
With the filters selected there were 1095 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 34 34 20.577777 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 34 34 20.577777 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 1.727777 $83.7900 $48.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 9 1.994446 $101.8200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.394444 $20.1300 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 0.866667 $44.2500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.361111 $18.4300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 2.450000 $125.0700 $51.0500
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Subtotal (Total Children Is Unduplicated) 27 34 7.794445 $393.5000 $50.4900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 34 90 23.978572 $1198.9400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3 3 1.944445 $97.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.644445 $132.2300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 1.800000 $90.0000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 4.142857 $103.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 122 127 865.714280 $43285.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 717 772 5538.992847 $55389.9500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 8 53.428571 $3816.9400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 8.285714 $473.9400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 4 19.714285 $1408.4000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 7.142857 $408.2900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 17.999999 $1285.9300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 31.285714 $1789.5400 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 12.571429 $174.4900 $13.8800
TRAV -TRAVS Travel by mile 1 1 2.142857 $0.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 762 1027 6592.788872 $114656.1000 $17.3900
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Total 1095 6621.161094 $115049.6000 $17.3800
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Number of Children (Unduplicated) With at Least One Authorization 798