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: 07-01-16 and 09-30-16 Date of Report: 10-26-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 950 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 0.266667 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 9.296032 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 9.562699 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.744444 $7.7600 $10.4200
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 2.677778 $133.8900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 5 5 6.000000 $300.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.005556 $0.4200 $75.5900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 10 10 5.227777 $392.0800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.461111 $34.5800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 11 11 5.688888 $315.7300 $55.5000
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Subtotal (Total Children Is Unduplicated) 21 32 21.805554 $1232.9600 $56.5400
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.516666 $25.8300 $49.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 38 38 15.232843 $761.6300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 6.071429 $434.7700 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 46 50 273.872224 $13693.6200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 145 200 270.037299 $13501.8500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 12 15 17.894445 $447.3600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 4.416667 $323.8300 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 4 19.242857 $962.1400 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 369 595 2428.361916 $24283.6200 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.311111 $20.2200 $65.0000
TRAV -TRAVS Travel by mile 1 1 3.642857 $1.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 381 912 3043.600314 $54606.4900 $17.9400
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Total 950 3074.968567 $55839.4500 $18.1600
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Number of Children (Unduplicated) With at Least One Authorization 385