Summary Report for FSPSAs Ending During the Report Period Center: 55
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 1094 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 26 14.611113 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 25 26 14.611113 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 10 14 2.868946 $143.4600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 8 8 7.087672 $354.3800 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 12.010958 $900.8300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 8.005479 $600.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 14.010958 $1050.8300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 2.005479 $111.3100 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 8 8 1.594444 $81.3900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 7 1.877778 $95.8600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.911111 $46.5100 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.233333 $11.9100 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.100000 $5.1100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 14 14 3.199999 $163.3500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.366667 $18.7200 $51.0500
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Subtotal (Total Children Is Unduplicated) 60 82 54.272824 $3584.0600 $66.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.210959 $16055.0000 $5000.0600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 12 2.542315 $127.1200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.433333 $10.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 119 148 88.505556 $4425.2800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 110 131 153.659527 $3841.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 83 166 86.583331 $4329.1600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 41 76 62.444440 $1561.1000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 80 46.438891 $2321.9600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 44 49.255555 $1231.3900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 85 99 64.772225 $3238.6300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 87 102 122.042066 $3051.0600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 12.857143 $321.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 16 83.714284 $4185.7200 $50.0000
INTR -T1013 INTERPRETER 1 1 0.900000 $45.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 24 165.178571 $11800.3600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 17 19 138.035717 $7895.6400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 14 14 63.359524 $4526.4000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 11 67.000000 $3829.7300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 37 227.428570 $16247.4900 $71.4400
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Subtotal (Total Children Is Unduplicated) 265 986 1438.362007 $89044.7700 $61.9100
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Total 1094 1507.245944 $92628.8300 $61.4600
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Number of Children (Unduplicated) With at Least One Authorization 313