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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2627 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 3 3 1.321004 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.321004 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 28 19.039575 $923.4300 $48.5000
EXIT -EXIT EXIT ASSESSMENT 47 47 48.043835 $2402.2000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.005479 $300.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.010958 $333.6100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 67 67 109.063009 $8179.7400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 25 25 32.049311 $2403.7100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 96 98 154.112321 $8553.2500 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 38 38 72.004110 $5400.3100 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.827778 $42.2600 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.100000 $5.1100 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 1.361644 $69.5100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 11 11 5.804642 $296.3300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.694445 $35.4500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.044444 $2.2700 $51.0000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 1.391781 $71.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 14 14 8.916515 $455.1900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.147945 $7.5500 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 19 19 11.655022 $594.9900 $51.0500
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Subtotal (Total Children Is Unduplicated) 221 378 485.278293 $30748.7800 $63.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 33 35 21.657687 $108289.0000 $5000.0300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.227397 $11.3700 $49.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 58 63 74.810387 $3740.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 5 1.027776 $25.6900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 213 235 384.995233 $19249.7400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.066667 $26.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 101 104 157.800002 $7890.0100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.366667 $34.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 33.666667 $1683.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 190 198 294.461900 $14723.0800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.900000 $97.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 232 245 1497.604744 $74880.3200 $50.0000
INTR -T1013 INTERPRETER 18 28 58.060447 $2903.0300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 259 444 1719.676434 $17196.7800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 34 34 193.892854 $13851.7400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 12.142857 $694.5700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 34 34 236.714283 $16910.8800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 12.142857 $694.0900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 30 207.857141 $14849.3500 $71.4400
TRAV -TRAVS Travel by mile 361 764 125663.083720 $55920.0800 $0.4500
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Subtotal (Total Children Is Unduplicated) 393 2246 130576.155720 $353671.8800 $2.7100
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Total 2627 131062.755017 $384420.6600 $2.9300
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Number of Children (Unduplicated) With at Least One Authorization 399