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: 04-01-17 and 06-30-17 Date of Report: 08-05-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 791 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 3 3 1.466666 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 11.085714 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 12.552380 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 7 8 9.750000 $487.5000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.127778 $9.5900 $75.0100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.772222 $57.9200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 12 12 5.700000 $427.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 1.183333 $88.7500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 11 4.488889 $336.6700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 21 21 7.827778 $434.4400 $55.5000
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Subtotal (Total Children Is Unduplicated) 32 58 29.850000 $1842.3600 $61.7200
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.016667 $3.8400 $230.4600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 45 44.858731 $2242.9400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 113 153 155.205848 $7760.2900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 1.887301 $47.1800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.411111 $20.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.300000 $15.0000 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 8.365080 $613.3400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 3 11.328571 $283.2200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 8 29.690476 $1484.5200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 376 504 1715.958229 $17159.5800 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.122222 $7.9400 $64.9900
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Subtotal (Total Children Is Unduplicated) 385 726 1970.144236 $29713.4000 $15.0800
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Total 791 2012.546616 $31555.7600 $15.6800
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Number of Children (Unduplicated) With at Least One Authorization 396