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 863 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
EXIT -EXIT EXIT ASSESSMENT 5 5 7.000000 $350.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.322222 $24.1700 $74.9900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 2.177778 $163.3400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.338889 $25.4200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 2.916667 $161.8800 $55.5000
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Subtotal (Total Children Is Unduplicated) 17 26 12.755556 $724.7900 $56.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 1.344444 $6722.0000 $4999.8400
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
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 1 1 1.733333 $127.0900 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 12 38.910317 $1945.5200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 355 546 2062.919823 $20629.2100 $10.0000
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Subtotal (Total Children Is Unduplicated) 370 831 2548.838081 $50980.5000 $20.0000
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Total 863 2581.817447 $51705.2900 $20.0300
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Number of Children (Unduplicated) With at Least One Authorization 373