Summary Report for FSPSAs Ending During the Report Period Center: 57
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 2143 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 4 4 3.083333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 2.566668 $94.9700 $37.0000
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Subtotal (Total Children Is Unduplicated) 8 8 5.650001 $94.9700 $16.8100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.255556 $12.4000 $48.5100
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 8 12.857143 $713.5700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 11.857143 $889.2800 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 18 18 9.428573 $481.3400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 51 52 19.123014 $976.2200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 22 24 26.376191 $1346.5100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 37 38 26.681745 $1362.1000 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.066667 $3.4100 $51.0700
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 65 68 32.415077 $1654.7800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 19 20 7.055555 $360.1800 $51.0500
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Subtotal (Total Children Is Unduplicated) 163 239 147.294442 $7883.8700 $53.5200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.833333 $41.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 78 82 54.133333 $2706.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 11.869842 $593.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 269 286 196.739680 $9836.9700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 46 46 301.714284 $7542.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 367 398 2543.138110 $127156.9500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 405 827 3112.055571 $31120.5600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 72 74 372.785715 $26631.8200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.633333 $36.2200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 44 46 213.285716 $15237.1400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 11 11 114.428571 $6540.7400 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 65 67 262.151586 $18728.1200 $71.4400
TRAV -TRAVS Travel by mile 27 37 19084.587306 $8492.6400 $0.4500
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Subtotal (Total Children Is Unduplicated) 473 1896 26270.356380 $264665.8500 $10.0700
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Total 2143 26423.300823 $272644.7000 $10.3200
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Number of Children (Unduplicated) With at Least One Authorization 492