Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 01-01-18 and 03-31-18 Date of Report: 05-05-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1911 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 1 1 1.300000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.300000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 30 17.510612 $849.2600 $48.5000
EXIT -EXIT EXIT ASSESSMENT 52 53 74.383105 $3719.1500 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.000000 $750.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.174049 $8.8900 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.032877 $1.6800 $51.0800
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.126027 $6.4300 $51.0400
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.101370 $5.1800 $51.0700
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.117809 $6.0100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.073973 $3.7800 $51.0700
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.317124 $16.1900 $51.0500
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Subtotal (Total Children Is Unduplicated) 84 107 116.836946 $6221.5700 $53.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 1.811568 $9057.5000 $4999.8100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 53 57 38.804850 $1940.2100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.255556 $31.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 184 225 302.921785 $15146.0800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.833333 $45.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 66 71 95.216669 $4760.8500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 21 27.833334 $1391.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 136 148 202.166664 $10108.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.833333 $45.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 10 11 61.500000 $3075.0000 $50.0000
INTR -T1013 INTERPRETER 28 42 76.738161 $3836.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 270 431 1496.051328 $14960.5000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 25.142858 $1796.2100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 5 25.714286 $1837.0300 $71.4400
SENS -V5264 EARMOLD 1 1 0.711111 $12.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 9 51.285716 $3663.8500 $71.4400
TRAV -TRAVS Travel by mile 388 767 119121.431387 $53009.0400 $0.4500
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Subtotal (Total Children Is Unduplicated) 395 1803 121532.251939 $124719.0000 $1.0300
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Total 1911 121650.388885 $130940.5700 $1.0800
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Number of Children (Unduplicated) With at Least One Authorization 399