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 501 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 2 2 0.008220 $0.4600 $55.3800
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.133333 $160.0000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $51.0500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.216438 $11.0500 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.224658 $11.4700 $51.0600
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Subtotal (Total Children Is Unduplicated) 46 50 31.507440 $1705.2900 $54.1200
EI Services, Class # 03
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 1 2 0.066666 $1.6700 $24.9800
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 9 10 26.193652 $1309.6800 $50.0000
INTR -T1013 INTERPRETER 7 8 70.714286 $3535.7100 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 4 4 16.142857 $1153.2500 $71.4400
TRAV -TRAVS Travel by mile 19 21 3816.528572 $1698.3600 $0.4500
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Subtotal (Total Children Is Unduplicated) 189 446 4328.493444 $27500.0100 $6.3500
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Total 501 4373.815170 $29205.2900 $6.6800
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Number of Children (Unduplicated) With at Least One Authorization 204