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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 830 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 29 32 14.900000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 32 14.900000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 4 2.483333 $120.4400 $48.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 0.322222 $16.4500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 0.711111 $36.3000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.855555 $43.6700 $51.0500
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Subtotal (Total Children Is Unduplicated) 9 13 4.372221 $216.8600 $49.6000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 36 110 21.588884 $1079.4200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.855556 $42.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.855556 $42.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 2 1.011111 $50.5600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 14 16 114.999999 $5750.0100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 575 645 4418.971419 $44189.7200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 7.142857 $510.2900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.142857 $65.3700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 2.000000 $142.8800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 11.571428 $661.4300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 11.285714 $806.2500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 9.571429 $547.4800 $57.2000
TRAV -TRAVS Travel by mile 1 1 4.142857 $1.8400 $0.4500
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Subtotal (Total Children Is Unduplicated) 613 785 4607.139667 $63890.8000 $13.8700
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Total 830 4626.411888 $64107.6700 $13.8600
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Number of Children (Unduplicated) With at Least One Authorization 641