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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2067 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
TCM -T1017TL TARGETED CASE MANAGEMENT 105 106 65.007936 $2405.2900 $37.0000
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Subtotal (Total Children Is Unduplicated) 105 106 65.007936 $2405.2900 $37.0000
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.577778 $29.5000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 52 53 24.074607 $1229.0300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.577778 $29.5000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 19 19 4.677779 $238.8100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.038889 $1.9900 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 41 41 12.222226 $623.9600 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.916667 $85.3900 $44.5500
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Subtotal (Total Children Is Unduplicated) 65 122 44.085724 $2238.1700 $50.7700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 0.711112 $35.5600 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 156 160 66.433335 $3321.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 35 17.461111 $873.0600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 281 288 128.578579 $6428.9700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 71 90 521.142847 $13028.6100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 492 509 2998.568241 $149928.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 503 521 3057.130144 $30571.3100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 74 92 297.071442 $21222.7600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.000000 $114.4000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 35 41 110.500008 $7894.1100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 2.000000 $114.3200 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 77 95 301.142871 $21513.6300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 8.642858 $119.9600 $13.8800
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Subtotal (Total Children Is Unduplicated) 580 1839 7511.382548 $255166.7900 $33.9700
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Total 2067 7620.476208 $259810.2400 $34.0900
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Number of Children (Unduplicated) With at Least One Authorization 604