Summary Report for FSPSAs Initiated During the Report Period Center: 05
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 570 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 2.104762 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 2.104762 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 5 5 5.073973 $253.7000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 35 39 41.413958 $2070.7100 $50.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 0.004110 $0.3100 $74.8200
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 0.002740 $0.1500 $54.6700
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.004110 $0.3100 $74.8200
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.090411 $55.6600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.090411 $4.6100 $51.0400
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Subtotal (Total Children Is Unduplicated) 46 51 47.685192 $2385.8600 $50.0300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 5.961111 $298.0600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 185 195 534.969839 $26748.4700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 47 47 67.683957 $3384.2100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.033333 $100.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 88 92 131.607351 $6580.3800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 135 147 168.984983 $8449.2700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 7.857143 $196.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5 5 39.438095 $1971.9100 $50.0000
INTR -T1013 INTERPRETER 9 11 120.714286 $6035.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 18.928571 $1352.2600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 18.928571 $1352.2600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 13.500000 $964.4300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 13.142857 $182.4200 $13.8800
TRAV -TRAVS Travel by mile 3 3 77.000000 $34.2700 $0.4500
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Subtotal (Total Children Is Unduplicated) 213 517 1222.750097 $57650.8900 $47.1500
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Total 570 1272.540051 $60036.7500 $47.1800
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Number of Children (Unduplicated) With at Least One Authorization 244