Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 07-01-17 and 09-30-17 Date of Report: 11-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1216 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 5 2.427777 $117.7400 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 21 21 7.625397 $164.3300 $21.5500
EXIT -EXIT EXIT ASSESSMENT 4 4 4.250000 $212.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 6 5.155555 $386.6600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 9 6.161110 $462.0800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 7 4.299999 $322.4900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 15 11.916666 $661.3700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 26 26 51.500000 $2858.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 17 34.000000 $2550.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 68 120 147.336504 $9235.4200 $62.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 10 10 3.772222 $867.6100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 33 38 43.254761 $2162.7400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 98 128 149.649998 $7482.5000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 4.766667 $119.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 5.866667 $293.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 5.583334 $279.1700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.766667 $69.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 5.066667 $253.3400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 5 20.685714 $1516.6800 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 22.723810 $568.1000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 310 333 1569.489683 $78474.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 355 538 1911.853971 $19118.5300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 11 40.771429 $2912.7200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 21.047619 $1203.9200 $57.2000
PHY -97110HM PT SESSION BY PT ASST 1 1 3.933333 $224.8300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 21.176190 $1512.8300 $71.4400
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Subtotal (Total Children Is Unduplicated) 366 1096 3835.408732 $122109.0500 $31.8400
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Total 1216 3982.745236 $131344.4700 $32.9800
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Number of Children (Unduplicated) With at Least One Authorization 366