Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 10-01-18 and 12-31-18 Date of Report: 02-05-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2903 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 4.666666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 4.666666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 29 12.553731 $608.8600 $48.5000
BEHV -H2014BA BEHAVIOR ANALYSIS-ASSOCIATE 1 1 11.571429 $564.2200 $48.7600
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.022222 $1.1100 $49.9500
EXIT -EXIT EXIT ASSESSMENT 61 62 60.783563 $3039.1800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 10.005479 $555.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 73 74 120.569858 $9042.7600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 41 41 66.041094 $4953.0900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 134 134 202.169852 $11220.4600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 70 70 117.557531 $8816.8300 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.305556 $117.7000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 3.991475 $203.7600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.972222 $49.6300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 8 8 18.342075 $936.3600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 18 18 6.417807 $327.6200 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.127778 $6.5200 $51.0600
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.200989 $10.2600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 14 5.181432 $264.5200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 4 4 3.472222 $177.2600 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.271233 $62.2200 $48.9400
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Subtotal (Total Children Is Unduplicated) 269 495 654.563027 $41759.1200 $63.8000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 35 36 17.509589 $87547.5000 $4999.9700
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.002740 $230.6200 $229.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 48 51 45.373519 $2268.6700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 1.538851 $38.4700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 229 245 421.989826 $21099.4900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.366667 $59.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 107 109 174.947617 $8747.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 5.300000 $132.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 33.600001 $1680.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 177 178 309.566666 $15478.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.166667 $79.1700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 32.000001 $2346.2400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 14 1203.428569 $30085.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 251 259 1685.638122 $84281.8000 $50.0000
INTR -T1013 INTERPRETER 20 29 76.823875 $3841.2000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 272 469 2153.893781 $21538.9100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 34 34 296.000003 $21146.2300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 46 46 368.796435 $26346.7900 $71.4400
SENS -V5264 EARMOLD 1 1 0.002740 $0.0500 $17.7400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 34 35 304.714290 $21768.7800 $71.4400
TRAV -TRAVS Travel by mile 330 868 171795.360208 $76448.9400 $0.4500
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Subtotal (Total Children Is Unduplicated) 348 2406 178933.020167 $425165.9300 $2.3800
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Total 2903 179592.249860 $466925.0500 $2.6000
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Number of Children (Unduplicated) With at Least One Authorization 375