Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 01-01-17 and 03-31-17 Date of Report: 05-05-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1915 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 8 8 6.211111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 6.211111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 25 3.879073 $188.1300 $48.5000
EXIT -EXIT EXIT ASSESSMENT 44 44 23.373972 $1168.7000 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 0.008220 $0.6200 $74.8200
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 6.004110 $333.2300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.004110 $0.3100 $74.8200
NURS -T1001 NURSING ASSESSMENT 1 1 0.002740 $0.1400 $49.2700
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 0.230137 $11.7500 $51.0400
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.084932 $4.3300 $51.0300
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.041096 $2.1000 $51.0600
SCREEN-T1023 SCREENING 3 3 0.983333 $49.1700 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.084932 $55.3800 $51.0500
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Subtotal (Total Children Is Unduplicated) 74 88 39.696655 $2113.8400 $53.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 0.386302 $1931.0000 $4998.6800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 69 84 16.142687 $807.0900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 1.716666 $42.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 176 223 331.242203 $16562.1000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 15.061904 $376.5500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 48 68.666665 $3433.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 6.266667 $156.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 32 38.925564 $1946.2500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.394444 $59.8600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 129 136 192.831747 $9641.6000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 3 3.400001 $85.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 10 11 50.428572 $2521.4300 $50.0000
INTR -T1013 INTERPRETER 16 20 49.359997 $2467.9900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 273 447 1500.045292 $15000.4300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 9 77.428573 $5531.4900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 35.000000 $2500.4000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 23 145.538162 $10397.2300 $71.4400
TRAV -TRAVS Travel by mile 393 755 97493.928496 $43384.8000 $0.4500
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Subtotal (Total Children Is Unduplicated) 403 1819 100028.763942 $116846.1200 $1.1700
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Total 1915 100074.671708 $118959.9600 $1.1900
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Number of Children (Unduplicated) With at Least One Authorization 414