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: 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 1779 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 1 1 5.857143 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 5.857143 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 24 5.020472 $243.4900 $48.5000
EXIT -EXIT EXIT ASSESSMENT 59 59 125.017809 $6250.8900 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.005479 $0.3100 $55.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 3.500000 $262.5000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.054795 $2.8000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.416667 $21.2700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.816059 $41.6600 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.038356 $1.9200 $50.0600
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Subtotal (Total Children Is Unduplicated) 84 96 142.869637 $7346.8300 $51.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 1.789878 $8949.5000 $5000.0600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 37 39 15.242526 $762.1000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.344444 $58.6100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 187 213 331.700001 $16585.0100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 6.050000 $151.2500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 64 100.233336 $5011.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 23 31.699999 $1585.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.866667 $21.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 140 151 225.300001 $11265.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.866667 $21.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 9 10 56.857143 $2842.8600 $50.0000
INTR -T1013 INTERPRETER 29 45 66.773765 $3338.6900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 251 371 1398.194013 $13981.9300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 76.357144 $5454.9500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 4 45.000000 $3214.8000 $71.4400
SENS -V5264 EARMOLD 1 1 0.443836 $7.9900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 12 59.428572 $4245.5800 $71.4400
TRAV -TRAVS Travel by mile 375 727 112987.981125 $50279.6600 $0.4500
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Subtotal (Total Children Is Unduplicated) 384 1682 115407.129117 $127777.9300 $1.1100
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Total 1779 115555.855897 $135124.7600 $1.1700
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Number of Children (Unduplicated) With at Least One Authorization 394