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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1723 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
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 1.700000 $62.9000 $37.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.700000 $62.9000 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $27.8300 $27.8300
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 8 13.285714 $737.3600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 13.285714 $996.4300 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 5 1.505556 $76.8600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.227778 $11.6300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 43 46 16.176190 $825.8000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 9 9 2.238890 $114.3000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 34 34 11.537302 $588.9800 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.138889 $7.0900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 50 50 23.223812 $1185.5900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.444444 $22.6900 $51.0400
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.450000 $22.0200 $48.9400
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Subtotal (Total Children Is Unduplicated) 95 166 84.514289 $4666.5800 $55.2200
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.433333 $21.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 81 42.819044 $2140.9400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 6.741270 $337.0700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 204 222 107.593646 $5379.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.571429 $14.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 64 68 415.857140 $10396.4400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 389 428 2573.200002 $128660.0200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 404 529 2683.230160 $26832.3100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 61 68 262.285719 $18737.6500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 8 25.285715 $1446.3400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 36 37 150.428571 $10746.6300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 8 8 48.142859 $2751.8400 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 59 61 204.285716 $14594.1600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 14.571429 $833.4900 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 21.571428 $299.4100 $13.8800
TRAV -TRAVS Travel by mile 14 21 5186.317460 $2307.9100 $0.4500
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Subtotal (Total Children Is Unduplicated) 496 1554 11743.334921 $225499.8000 $19.2000
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Total 1723 11829.549210 $230229.2800 $19.4600
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Number of Children (Unduplicated) With at Least One Authorization 500