Summary Report for FSPSAs Ending During the Report Period Center: 05
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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 918 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 5 5 13.814286 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 13.814286 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 1.038356 $51.9200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 36 40 23.886435 $1194.3500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.500000 $112.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 1.500000 $112.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 4.722506 $262.1000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.133333 $160.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.090411 $4.6100 $51.0400
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 19 4.175345 $213.1500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 4.457533 $227.5600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 38 40 10.144359 $517.8700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 1.232877 $62.9300 $51.0500
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Subtotal (Total Children Is Unduplicated) 98 127 54.881155 $2919.5000 $53.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.468645 $2343.0000 $4999.5200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 33 17.879364 $893.9600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 147 179 193.838252 $9691.9100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 4.339682 $108.4900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 34 37.778352 $1888.9200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 60 54.751583 $2737.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 83 91 88.960178 $4448.0200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.300000 $32.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 13 28.047618 $701.1900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 160 173 973.662154 $48683.0600 $50.0000
INTR -T1013 INTERPRETER 7 8 70.714286 $3535.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 34 163.142856 $11654.9100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 22.428572 $1282.9100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 35 36 132.908937 $9495.0200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 16.098434 $920.1900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 82 85 449.554699 $32116.1900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 24.142857 $335.1000 $13.8800
TRAV -TRAVS Travel by mile 19 21 3816.528572 $1698.3600 $0.4500
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Subtotal (Total Children Is Unduplicated) 209 786 6096.545041 $132566.9900 $21.7400
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Total 918 6165.240482 $135486.4800 $21.9800
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Number of Children (Unduplicated) With at Least One Authorization 232