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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 940 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 1 1 4.142857 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 4.142857 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 2 2.000000 $102.1000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 5.031746 $256.8700 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.416667 $72.3200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 6.431746 $328.3400 $51.0500
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Subtotal (Total Children Is Unduplicated) 5 14 16.880159 $861.7400 $51.0500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 0.511112 $25.5600 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 210 216 241.533327 $12076.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 30 41.550794 $2077.5400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 257 261 240.455547 $12022.7500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 16 16 113.252381 $5662.6300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 384 395 2581.093659 $25810.9400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 4.714286 $336.7900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.857143 $106.2300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 4.285714 $306.1700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 2 6.571429 $375.6200 $57.1600
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Subtotal (Total Children Is Unduplicated) 390 925 3235.825392 $58800.8800 $18.1700
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Total 940 3256.848408 $59662.6200 $18.3200
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Number of Children (Unduplicated) With at Least One Authorization 394