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: 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 2429 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 29 30.520168 $1480.2300 $48.5000
EXIT -EXIT EXIT ASSESSMENT 57 57 58.241509 $2912.0800 $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 26 26 32.399996 $2430.0200 $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 4 4 8.166666 $416.9100 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.422222 $21.5500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 3.191781 $162.9400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 13.452262 $686.7300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 1.855555 $94.7200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.191781 $162.9400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 16 16 9.016112 $460.2700 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.235616 $12.0300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 14 7.701903 $393.1800 $51.0500
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Subtotal (Total Children Is Unduplicated) 208 398 523.596927 $32673.3300 $62.4000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 34 26.976332 $134881.5000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 54 58 73.731023 $3686.5400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 5 1.027776 $25.6900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 191 205 377.429653 $18871.5200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 102 102 215.471430 $10773.5800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.666667 $41.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 21 30.800002 $1540.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.666667 $41.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 169 172 280.033334 $14001.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 5.366668 $134.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 199 208 1406.361909 $70318.0500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 9.428571 $471.4300 $50.0000
INTR -T1013 INTERPRETER 18 28 59.512828 $2975.6500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 225 398 1653.219315 $16532.1800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 41 333.864285 $23851.2400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.285714 $163.2900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.000000 $629.2000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 38 38 304.433332 $21748.7000 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 2.714285 $193.9100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 5.571429 $318.4600 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 27 245.357143 $17528.3100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 13.285714 $184.4100 $13.8800
TRAV -TRAVS Travel by mile 260 671 113766.251935 $50625.9800 $0.4500
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Subtotal (Total Children Is Unduplicated) 295 2031 118827.456012 $389538.8000 $3.2800
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Total 2429 119351.052939 $422212.1300 $3.5400
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Number of Children (Unduplicated) With at Least One Authorization 317