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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1155 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 0.511111 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 3.452381 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 3.963492 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.172222 $3.3100 $19.2000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 36 37 30.944444 $679.2300 $21.9500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.366667 $9.3600 $25.5300
EXIT -EXIT EXIT ASSESSMENT 5 5 125.071429 $6253.5700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.227778 $17.0900 $75.0100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 9 4.966666 $372.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 15 26 12.233332 $917.4900 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.216667 $16.2500 $75.0100
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 8 11 14.708730 $1103.1500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 19 32 38.106349 $2114.9000 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 16 16 23.450793 $1301.5300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 4.511111 $338.3300 $75.0000
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Subtotal (Total Children Is Unduplicated) 72 145 255.976188 $13175.2000 $51.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.422222 $2111.0000 $4999.7400
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.522222 $26.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 1.766666 $88.3300 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 13 13 4.183333 $1000.6500 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 31 37 26.005555 $1300.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 3.000000 $75.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 96 119 149.536509 $7476.8300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 0.311111 $7.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 4.533334 $226.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 3.133334 $156.6700 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 8 23.864287 $1749.7400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 11 41.361904 $1034.0500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 317 338 1810.153186 $90507.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 338 462 1987.385729 $19873.8500 $10.0000
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Subtotal (Total Children Is Unduplicated) 352 1004 4056.179392 $125634.5700 $30.9700
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Total 1155 4316.119072 $138809.7700 $32.1600
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Number of Children (Unduplicated) With at Least One Authorization 357