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: 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 902 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 6.100000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.066667 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 6.166667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 4.604763 $235.0800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.077778 $3.9700 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 4.465874 $227.9800 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 9 15 9.148415 $467.0300 $51.0500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.044444 $2.2200 $49.9500
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 113 51.220631 $2561.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 11 3.994444 $199.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 238 245 102.593652 $5129.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.888889 $22.2200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 23 24 142.285717 $7114.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 460 483 3016.645205 $30166.4800 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 1.285714 $91.8500 $71.4400
TRAV -TRAVS Travel by mile 4 4 74.857143 $33.3100 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 469 884 3393.815839 $45320.7800 $13.3500
-------------------------------------------------------------------------------------------------------------------------------------
Total 902 3409.130921 $45787.8100 $13.4300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 479