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 465 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
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Subtotal (Total Children Is Unduplicated) 3 3 5.666666 $0.0000 $0.0000
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 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 32 37 21.320548 $1142.1300 $53.5700
EI Services, Class # 03
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 9 11 80.642859 $4032.1400 $50.0000
INTR -T1013 INTERPRETER 7 7 29.500001 $1474.9900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 6.214286 $443.9500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 12.571429 $898.1000 $71.4400
TRAV -TRAVS Travel by mile 7 7 237.885715 $105.8600 $0.4500
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Subtotal (Total Children Is Unduplicated) 179 425 891.994212 $33146.5200 $37.1600
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Total 465 918.981426 $34288.6400 $37.3100
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Number of Children (Unduplicated) With at Least One Authorization 205