Summary Report for FSPSAs Ending During the Report Period Center: 05
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 1283 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 12 12 17.204762 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 12 17.204762 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 5.428571 $678.5800 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 4 4 4.073973 $203.7000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 50 60 69.196347 $3459.8200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.005480 $0.4100 $73.9100
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 0.012329 $0.9200 $74.8200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 0.057534 $4.3100 $74.8300
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 20 20 6.058908 $454.3900 $74.9900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 28 28 4.089048 $226.9100 $55.4900
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 22 22 2.064389 $154.7800 $74.9700
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 4.104110 $209.5100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 23 23 6.195966 $316.3200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 5 1.852055 $94.5400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 26 26 6.805480 $347.4200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 48 48 17.546953 $895.7900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 8 8 4.493151 $229.3700 $51.0500
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Subtotal (Total Children Is Unduplicated) 209 275 135.984294 $7576.7500 $55.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 10.668841 $53344.0000 $4999.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 3.216667 $160.8400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 199 223 266.702776 $13335.1400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.002740 $0.0700 $24.6400
CONOF -CONOF CONSULT, OT, FACE TO FACE 54 59 52.969844 $2648.5100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 80 82 82.561783 $4128.0800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 145 160 172.705108 $8635.2600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 20 32 92.557146 $2313.9200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 191 210 1136.061902 $56803.1300 $50.0000
INTR -T1013 INTERPRETER 10 11 91.319046 $4565.9500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 45 234.464284 $16750.1400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.071429 $175.6800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 53 54 220.433340 $15747.7300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 2.357143 $134.7300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 93 100 500.392856 $35748.1100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 6.357143 $88.2400 $13.8800
TRAV -TRAVS Travel by mile 3 3 77.000000 $34.2700 $0.4500
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Subtotal (Total Children Is Unduplicated) 255 996 2952.842048 $214613.7600 $72.6800
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Total 1283 3106.031104 $222190.5200 $71.5400
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Number of Children (Unduplicated) With at Least One Authorization 354