Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3178 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 25 25 33.471430 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 25 25 33.471430 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 15 15 20.436660 $991.1800 $48.5000
EXIT -EXIT EXIT ASSESSMENT 136 136 272.000000 $13600.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.005479 $300.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 3.000000 $225.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 1.500000 $112.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 8 15.000000 $832.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 8.000000 $600.0000 $75.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 157 173 330.942139 $17123.6400 $51.7400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 15 15 6.828006 $341.4000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 195 213 223.729305 $11186.4500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 76 88 194.022407 $9701.1300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 15 16.383333 $819.1700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 41 63.355560 $3167.8000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.400000 $35.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 48 52 84.307937 $4215.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.400000 $35.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 18 149.914287 $7495.7200 $50.0000
INTR -T1013 INTERPRETER 105 134 311.338094 $15566.9200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 758 1078 5511.809018 $55118.0500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 25.142857 $1796.2100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 5 17.123811 $1223.3200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 15 112.571430 $8042.0900 $71.4400
TRAV -TRAVS Travel by mile 802 1300 7320.530089 $3257.6400 $0.4500
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Subtotal (Total Children Is Unduplicated) 821 2980 14040.856134 $127001.2900 $9.0500
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Total 3178 14405.269703 $144124.9200 $10.0100
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Number of Children (Unduplicated) With at Least One Authorization 829