Summary Report for FSPSAs Initiated During the Report Period Center: 02
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 1522 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 2 2 6.890476 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 6.890476 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 26 4.837594 $234.6200 $48.5000
EXIT -EXIT EXIT ASSESSMENT 52 52 142.285064 $7114.2600 $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 0.177778 $9.0800 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.221918 $11.3300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.177778 $9.0800 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.355556 $18.1500 $51.0600
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.147945 $7.4000 $49.9800
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Subtotal (Total Children Is Unduplicated) 80 90 159.709112 $8188.7100 $51.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.221918 $1109.5000 $4999.5900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.060274 $13.8700 $230.1000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 41 23.089863 $1154.4700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 160 183 341.366667 $17068.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.733333 $68.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 62 90.233336 $4511.6800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 17 28.349999 $1417.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 109 114 188.899998 $9444.9900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.733333 $68.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 4 16.142858 $807.1400 $50.0000
INTR -T1013 INTERPRETER 28 44 41.826146 $2091.3100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 211 307 1252.168955 $12521.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 24.142858 $1724.7600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 11.571429 $826.6600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 4 20.000000 $1428.8000 $71.4400
TRAV -TRAVS Travel by mile 278 643 103610.371541 $46106.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 289 1430 105656.045841 $100417.3000 $0.9500
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Total 1522 105822.645429 $108606.0100 $1.0300
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Number of Children (Unduplicated) With at Least One Authorization 310