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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1092 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 2 2 9.969842 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2 2 9.969842 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 25 20.316483 $985.3500 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 3 1.172223 $58.6200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 28 28 30.089726 $1504.4900 $50.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.500000 $249.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.500000 $187.5000 $75.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.1000 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 53 63 63.578432 $3288.8500 $51.7300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.000000 $15000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 44 34.891848 $1744.5900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 2 1.273611 $63.6800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 2.079167 $51.9800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 132 139 225.997978 $11299.9200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 75 79 130.428568 $6521.4200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.500000 $87.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 16 26.166666 $1308.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.766667 $44.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 117 122 186.652380 $9332.6200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.766667 $119.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 7 18.376190 $918.8100 $50.0000
INTR -T1013 INTERPRETER 12 20 40.402151 $2020.1100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 163 281 1087.895954 $10878.9600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 8.714285 $622.5500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 15.142857 $1081.8000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 17.857142 $1275.7200 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 1.000000 $37.0000 $37.0000
TRAV -TRAVS Travel by mile 149 295 61801.827990 $27501.8100 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 196 1027 63611.740121 $89910.1300 $1.4100
-------------------------------------------------------------------------------------------------------------------------------------
Total 1092 63685.288395 $93198.9800 $1.4600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 205