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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 790 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 2 2 1.066667 $39.4700 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.066667 $39.4700 $37.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 0.961112 $49.0700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.466667 $23.8300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 0.961112 $49.0700 $51.0500
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Subtotal (Total Children Is Unduplicated) 4 9 2.388891 $121.9600 $51.0500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 3 0.077778 $3.8900 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 142 145 86.309526 $4315.5000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 30 20.660318 $1033.0200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 215 219 110.932537 $5546.6300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5 6 36.428572 $1821.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 366 376 2305.001610 $23050.0100 $10.0000
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Subtotal (Total Children Is Unduplicated) 371 779 2559.410341 $35770.4600 $13.9800
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Total 790 2562.865899 $35931.9000 $14.0200
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Number of Children (Unduplicated) With at Least One Authorization 375