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 746 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
EXIT -EXIT EXIT ASSESSMENT 4 4 4.250000 $212.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 1.511111 $113.3300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 0.638889 $47.9200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.666666 $50.0000 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 2.794444 $155.0900 $55.5000
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Subtotal (Total Children Is Unduplicated) 15 21 12.288887 $696.5800 $56.6800
EI Services, Class # 03
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 4 18.035714 $901.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 355 538 1911.853971 $19118.5300 $10.0000
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Subtotal (Total Children Is Unduplicated) 362 725 2148.844446 $30729.7300 $14.3000
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Total 746 2161.133333 $31426.3100 $14.5400
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Number of Children (Unduplicated) With at Least One Authorization 362