Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 04-01-16 and 06-30-16 Date of Report: 08-06-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1403 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 6 20.223810 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 6 20.223810 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.288889 $13.6000 $47.0900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 24 24 13.945238 $306.1000 $21.9500
EXIT -EXIT EXIT ASSESSMENT 5 5 7.000000 $350.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.083333 $81.2500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 11 11.483335 $861.2600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 22 30 27.605557 $2070.4300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 10 12 11.866667 $890.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 35 47 40.225399 $2232.5200 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 35 35 70.000000 $3885.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 12.022222 $901.6700 $75.0000
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Subtotal (Total Children Is Unduplicated) 110 174 195.520640 $11591.8300 $59.2900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 7 5.027777 $25138.5000 $4999.9200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.722222 $36.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 21 21 9.505555 $475.2800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.205556 $14.7200 $71.6300
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 1.586508 $379.4900 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 31 40 159.978571 $7998.9300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 2.272223 $56.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 140 186 248.129370 $12406.5000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 13 19 23.322223 $583.0600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 11 29.085713 $2132.5600 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 9.233333 $230.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 331 377 1911.165853 $95558.3700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 355 547 2064.419823 $20644.2100 $10.0000
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Subtotal (Total Children Is Unduplicated) 380 1223 4464.654727 $165655.3700 $37.1000
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Total 1403 4680.399177 $177247.2000 $37.8700
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Number of Children (Unduplicated) With at Least One Authorization 384