Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 1281 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 3.221429 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 3.221429 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 1.744444 $89.0500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 2.077779 $106.0800 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 0.950000 $48.5000 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 0.944445 $48.2200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 22 23 7.200003 $367.5800 $51.0500
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Subtotal (Total Children Is Unduplicated) 32 45 16.916671 $920.4200 $54.4100
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 7.839682 $391.9900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 106 108 87.593647 $4379.6600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 9.177777 $458.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 267 269 194.552383 $9727.6300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 20 151.092067 $7554.5900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 362 768 3031.993678 $30319.9100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 40.857144 $2918.8300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 13.714286 $979.7500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 20.785715 $1188.1100 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $474.2400 $237.1200
SENS -V5264 EARMOLD 1 1 0.377778 $6.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 7 46.342858 $3310.7200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 6.714286 $93.1900 $13.8800
TRAV -TRAVS Travel by mile 22 28 28776.333332 $12805.4700 $0.4500
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Subtotal (Total Children Is Unduplicated) 365 1233 32389.374633 $74609.7700 $2.3000
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Total 1281 32409.512733 $75530.1800 $2.3300
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Number of Children (Unduplicated) With at Least One Authorization 375