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: 07-01-18 and 09-30-18 Date of Report: 11-06-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 623 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 2 3 2.400000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 3 2.400000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 2 2 41.000000 $2050.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 2.372222 $177.9200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 2.057936 $154.3400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.544444 $40.8300 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 4.294444 $238.3400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 2.650000 $198.7500 $75.0000
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Subtotal (Total Children Is Unduplicated) 13 23 52.919046 $2860.1800 $54.0500
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.833333 $41.6700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.494444 $113.7100 $229.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 21 12.826985 $641.3500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 71 90 103.908730 $5195.4400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 1.094444 $27.3600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 4.172221 $208.6100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 8.644443 $432.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 4.066667 $203.3400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 13 14 91.655556 $4582.7800 $50.0000
INTR -T1013 INTERPRETER 3 3 8.333333 $416.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 320 445 1834.139670 $18341.3900 $10.0000
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Subtotal (Total Children Is Unduplicated) 326 597 2071.169826 $30277.8400 $14.6200
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Total 623 2126.488872 $33138.0100 $15.5800
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Number of Children (Unduplicated) With at Least One Authorization 328