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: 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 865 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 7 7 29.891270 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 29.891270 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 6 6 6.844444 $342.2200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 0.933334 $70.0100 $75.0100
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 10 10 3.888890 $291.6800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 0.616667 $46.2500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 13 4.866667 $270.1000 $55.5000
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Subtotal (Total Children Is Unduplicated) 22 38 19.150002 $1120.2500 $58.5000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 1.400000 $70.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 46 48 70.511113 $3525.5700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 124 161 223.612697 $11180.6400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 9 8.899999 $222.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.933333 $48.3300 $25.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 398 593 2222.884922 $22228.8700 $10.0000
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 1.261111 $598.0600 $474.2400
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Subtotal (Total Children Is Unduplicated) 401 820 2534.503175 $38023.9600 $15.0000
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Total 865 2583.544447 $39144.2200 $15.1500
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Number of Children (Unduplicated) With at Least One Authorization 403