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 945 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
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 0.285714 $15.8600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.285714 $21.4300 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.600000 $30.6300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 11 11 3.377778 $172.4400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.411111 $20.9900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 10 10 3.050000 $155.7000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 3.766667 $192.2900 $51.0500
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Subtotal (Total Children Is Unduplicated) 24 40 12.776984 $659.3300 $51.6000
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 2 2 18.857142 $471.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 20 126.857145 $6342.8500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 404 529 2683.230160 $26832.3100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 28.428572 $2030.9300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 4 15.214285 $1086.9100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 11.857143 $677.7500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 13.785715 $984.8500 $71.4400
TRAV -TRAVS Travel by mile 14 21 5186.317460 $2307.9100 $0.4500
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Subtotal (Total Children Is Unduplicated) 412 905 8242.706344 $48628.5500 $5.9000
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Total 945 8255.483328 $49287.8800 $5.9700
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Number of Children (Unduplicated) With at Least One Authorization 423