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: 07-01-18 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 655 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 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.000000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.388889 $18.8600 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.461111 $10.9300 $23.7000
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 4.488890 $336.6800 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 10 10 4.611112 $345.8400 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.094444 $7.0800 $74.9700
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 6 3.500000 $262.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 6.305555 $349.9600 $55.5000
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Subtotal (Total Children Is Unduplicated) 22 38 20.850001 $1381.8400 $66.2800
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.150000 $34.5000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 20 11.826985 $591.3500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 56 68 83.680952 $4184.0500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 23 17.955555 $897.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 19 23.379363 $1168.9700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 18 20 13.950000 $697.5000 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 2.266667 $166.1900 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 4.444444 $111.1100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 12 54.198414 $2709.9200 $50.0000
INTR -T1013 INTERPRETER 2 2 9.633333 $481.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 337 448 1742.268263 $17422.6600 $10.0000
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Subtotal (Total Children Is Unduplicated) 347 616 1963.753976 $28465.6900 $14.5000
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Total 655 1985.603977 $29847.5300 $15.0300
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Number of Children (Unduplicated) With at Least One Authorization 349