Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 07-01-15 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 3934 FSPSA's found of which 242 had no frequency modifier field, FORCE FREQ MODIFIER to 0
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
CASE -CASE NON-TCM CASE MANAGEMENT 2 4 3.142857 $116.2900 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 11 17 137.387701 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 21 140.530558 $116.2900 $0.8300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 5 280.611111 $13609.6400 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.283333 $13.2600 $46.7900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.283333 $33.8800 $119.5900
EVAL -96111 DEVELOPMENTAL EVALUATION 2 4 10.000000 $500.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 17 17 42.707718 $2135.3900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 6 3.688889 $276.6700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 26 30 22.619845 $1696.5200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 22 32 14.905553 $1117.9000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 15 16 7.822225 $434.1500 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.500000 $83.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 5 3.055556 $229.1700 $75.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 11 14 5.282876 $792.4200 $150.0000
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 12.466667 $636.4300 $51.0500
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Subtotal (Total Children Is Unduplicated) 85 133 405.227106 $21558.6600 $53.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 66.972222 $334861.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 48 49 53.456467 $2672.8200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.772222 $55.3000 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 106 146 453.126224 $22656.3200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 7 3.622223 $90.5600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 227 404 981.326190 $49066.3100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 22 30 81.966663 $2049.1600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 6 16.453968 $1206.4000 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 13.014287 $325.3600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 60 82 492.776081 $24638.8200 $50.0000
INTR -T1013 INTERPRETER 1 1 8.000000 $400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 607 1285 11397.690503 $113976.9100 $10.0000
SENS -V5264 EARMOLD 1 1 0.283333 $5.1000 $18.0000
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 574 1745 10199.769846 $5099.8800 $0.5000
TRAV -TRAVS Travel by mile 11 15 4706.813319 $2094.5300 $0.4500
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Subtotal (Total Children Is Unduplicated) 868 3780 28476.043548 $559198.4500 $19.6400
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Total 3934 29021.801212 $580873.4000 $20.0200
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Number of Children (Unduplicated) With at Least One Authorization 872