Summary Report for FSPSAs Ending During the Report Period Center: 07
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 413 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 1.938890 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.938890 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 16 16 9.303577 $465.1700 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.172222 $8.7900 $51.0400
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Subtotal (Total Children Is Unduplicated) 18 18 10.475799 $525.0100 $50.1200
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 4.800783 $240.0400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 84 94 44.314102 $2215.7400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.011111 $0.2800 $24.9800
CONIF -CONIF CONSULT, ITDS FACE TO FACE 135 225 533.906799 $26695.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 10 16.285715 $407.1500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 6 7.400001 $370.0100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 2.633333 $131.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 6 6.661905 $333.1000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 6.285714 $157.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 10 11 82.071429 $4103.5700 $50.0000
INTR -T1013 INTERPRETER 2 2 16.714286 $835.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 0.142857 $1.4300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 10.000000 $714.4000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 12.857143 $918.5100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 24.714286 $1765.5900 $71.4400
TRAV -TRAVS Travel by mile 17 23 146.785715 $65.3200 $0.4400
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Subtotal (Total Children Is Unduplicated) 211 392 915.585179 $38954.9900 $42.5500
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Total 413 927.999868 $39480.0000 $42.5400
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Number of Children (Unduplicated) With at Least One Authorization 222