Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 10-01-16 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 895 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 3 3 5.666666 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.066667 $39.4700 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 4 6.733333 $39.4700 $5.8600
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 3 3 3.000000 $150.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 24 29 14.312328 $715.6200 $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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 34 34 8.065754 $411.7600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 3.805478 $194.2700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 55 55 23.354596 $1192.2700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 0.643836 $32.8700 $51.0500
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Subtotal (Total Children Is Unduplicated) 103 138 56.190212 $2922.2400 $52.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 12 12.780954 $639.0600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 148 163 214.172616 $10708.6300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.700000 $67.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 45 61.706743 $3085.3300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 62 65 89.156856 $4457.8200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 103 111 144.662753 $7233.1600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 10 55.300001 $1382.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 157 166 1086.587553 $54329.3200 $50.0000
INTR -T1013 INTERPRETER 7 7 29.500001 $1474.9900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 32 34 222.889434 $15923.2000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 20.928572 $1197.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 37 38 262.447621 $18749.2500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 21.642857 $1237.1100 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 76 81 498.750001 $35630.6800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 46.428572 $644.4300 $13.8800
TRAV -TRAVS Travel by mile 7 7 237.885715 $105.8600 $0.4500
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Subtotal (Total Children Is Unduplicated) 214 753 3009.540249 $166865.9300 $55.4500
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Total 895 3072.463794 $169827.6400 $55.2700
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Number of Children (Unduplicated) With at Least One Authorization 243