Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3758 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 44 44 111.756350 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 19 21 480.000000 $17760.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 63 65 591.756350 $17760.0000 $30.0100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 19 11.265449 $546.3800 $48.5000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.000000 $76.9400 $38.4700
EXIT -EXIT EXIT ASSESSMENT 155 157 311.750000 $15587.5000 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 13 14 28.000000 $1554.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 19.500000 $1462.5000 $75.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 189 207 383.515449 $20028.3700 $52.2200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.000000 $15000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 3.722222 $186.1100 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 3.877778 $891.8900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 227 242 364.993082 $18249.6700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 7.750000 $193.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 95 105 147.416666 $7370.8300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.333333 $33.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 26 33.588888 $1679.4400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 60 69.957146 $3497.8700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 64 66 83.933333 $4196.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.066667 $26.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 23 27 153.923809 $7696.2100 $50.0000
INTR -T1013 INTERPRETER 142 150 407.378569 $20368.9400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 855 1256 5783.930149 $57839.3000 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 10.571429 $755.2200 $71.4400
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 17.142857 $1224.6900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 8.857143 $122.9400 $13.8800
TRAV -TRAVS Travel by mile 1004 1528 6145.434911 $2734.7100 $0.4400
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Subtotal (Total Children Is Unduplicated) 1072 3486 13248.877982 $142068.2200 $10.7200
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Total 3758 14224.149781 $179856.5900 $12.6400
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Number of Children (Unduplicated) With at Least One Authorization 1099