Summary Report for FSPSAs Initiated During the Report Period Center: 57
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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1318 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 91 92 55.844447 $2066.2500 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 91 92 55.844447 $2066.2500 $37.0000
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.466667 $23.8300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 3.355555 $171.3000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.466667 $23.8300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 3.472222 $177.2600 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 5 2.461111 $125.6400 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 13 17 11.222222 $572.8900 $51.0500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 0.300000 $15.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 211 215 102.171441 $5108.6300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 32 25.706351 $1285.3200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 315 323 163.784133 $8189.2300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 10.000000 $250.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 44 45 258.571427 $12928.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 544 571 3550.157132 $35501.5700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 20.214285 $1444.1200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 11.285714 $645.5400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 2 2 24.142857 $1724.7700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.142857 $236.8100 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 12.857141 $918.5300 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 554 1209 4183.333338 $68248.0800 $16.3100
-------------------------------------------------------------------------------------------------------------------------------------
Total 1318 4250.400007 $70887.2300 $16.6800
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 619