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: 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 1405 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 14 14 11.631748 $430.3800 $37.0000
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Subtotal (Total Children Is Unduplicated) 14 14 11.631748 $430.3800 $37.0000
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 6.383333 $325.8700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 2.911111 $148.6100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 5.799999 $296.0800 $51.0500
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Subtotal (Total Children Is Unduplicated) 20 31 16.094443 $821.6100 $51.0500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 5 0.888890 $44.4500 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 190 193 184.380160 $9219.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 37 108.579365 $5428.9700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 253 257 193.438093 $9671.9100 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 17 17 173.428571 $4335.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 394 401 2758.652345 $137932.7400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 395 403 2764.223774 $27642.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 20 104.500002 $7465.4800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.714286 $155.2600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 8 8 57.000001 $4072.0800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 18 105.285716 $7521.6100 $71.4400
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Subtotal (Total Children Is Unduplicated) 410 1360 6453.091203 $213489.4800 $33.0800
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Total 1405 6480.817394 $214741.4800 $33.1300
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Number of Children (Unduplicated) With at Least One Authorization 422